Reducing stillbirth: Safer Baby Bundle

Safer Baby Bundle (SBB) is a national package of education and awareness measures aimed at reducing rates of stillbirth.

For every 1000 babies born in the ACT, 7 will die before birth. Stillbirth is a serious public health concern and affects a large number of families and communities within our territory and across Australia.

The Stillbirth Centre for Research Excellence created the Safer Baby Bundle to address key evidence-practice gaps within the maternity care system. It aims to reduce the number of stillbirths that occur after 28 weeks gestation by 20%.

The Safer Baby Bundle is designed to improve the care women and their families receive by targeting 5 key practice areas:

smoking cessation
fetal growth restriction
decreased fetal movements
side sleeping
timing of birth.

Australia's stillbirth rate

Throughout Australia, 6 babies are stillborn each day, carrying significant and long-lasting effects in parents, families, care providers, and society.

In 2015, Australia’s stillbirth rate was 35% higher compared with the best performing countries globally. The national stillbirth rate as of 2020 is 7.7 stillbirths per 1,000 births. The rate is almost double amongst Aboriginal and Torres Strait Islander women at 11.9 stillbirths per 1,000 births.

While Australia’s overall stillbirth rate has been slowly decreasing, it is estimated that approximately 20-30% of stillbirths could have been prevented if inadequate or inappropriate care practices were addressed.

Smoking cessation

Smoking in pregnancy is one of the largest avoidable causes of stillbirth and serious adverse pregnancy outcomes.

Within Australia 9% of women smoke at some time during their pregnancy. While the overall rate of smoking in pregnancy have decreased, and continue to decrease, rates continue to be higher in women from disadvantaged backgrounds, teenagers, and Aboriginal and Torres Strait Islander women.

Carbon monoxide from smoking has 200 times stronger affinity to haemoglobin compared to oxygen, inhibiting the release of oxygen into the cells. Chronic mild hypoxia of foetal tissue can persist for five or six hours after the woman has stopped smoking.

Smoking in pregnancy increases risks of miscarriage, stillbirth, placental abruption, congenital abnormalities, preterm birth, small for gestational age, and ongoing impairments to the growth and development of the baby after birth.

Babies born to mothers who smoked during pregnancy or are exposed to second hand smoke are at greater risk of sudden unexpected death in infancy (SUDI) and impaired or slow growth and development. They are also at greater risk of developing diseases later in life such as breathing problems, heart disease, diabetes, and obesity.

Go to these websites for more resources:

Fetal growth restriction

Fetal growth restriction (FGR) is best defined as a fetus who has not reached its growth potential and is growing slower than expected. Small for gestational age is often used interchangeably with fetal growth restriction. However, some growth restricted fetuses are not small for gestational age, just like not every small for gestational age fetus is growth restricted.

Slowed growth can indicate placental insufficiency and is an increased risk factor for stillbirth. Fetal growth restriction is also associated with an increased risk of neonatal death, perinatal morbidity and adverse health outcomes in later life.

All women should be offered assessment for their individual risk factors for FGR early in pregnancy and throughout their antenatal care. This done by assessing maternal characteristics and medical history, previous obstetric history, and risk factors which may arise or evolve throughout pregnancy.

All women should be offered to have their symphysial fundal height measured at each antenatal visit from 24 weeks. This measurement, if taken, is to be plotted on a growth chart at each visit and monitored to ensure a healthy growth trajectory. If there is suspected static or slow growth as per symphysial fundal height measurements, appropriate surveillance, monitoring, and follow up should be offered to the woman.

Go to these websites for more resources:

Decreased fetal movements

Women usually start to feel their babies move between 16 and 24 weeks of pregnancy, regardless of placental location. These early movements are often described as ‘flutters’ or ‘butterflies’. As pregnancy progresses, the descriptions of movement often change to reflect the increasing strength and complex limb movements of the developing baby.

It is a misconception that fetal movements decrease in late pregnancy. While near term fetuses’ have longer active and rest cycles, movements should be felt right up until the baby is born. By the final trimester of pregnancy, fetal movements are often described as ‘rolling’, ‘stretching’ or ‘pushing’.

It is important to note that there is no set number of movements required to be considered normal or reassuring. Rather, maternal perception of their baby’s individual pattern of movements and what is normal for their baby is the best indication of fetal wellbeing.

Decreased fetal movements is associated with low birth weight, preterm birth, congenital and chromosomal abnormalities, fetal maternal haemorrhage, intrauterine infections, perinatal brain injuries, umbilical cord complications, and placental insufficiency.

If women have any concerns about a reduction or change in their baby’s normal pattern of movement, they should contact their care provider immediately.

Go to Stillbirth Centre of Research Excellence in Stillbirth to read more:

Decreased Fetal Movements

Side sleeping

Going to sleep in a supine position in the final trimester of pregnancy is an identified and modifiable risk factor for stillbirth. In fact, it is estimated that 1 in 10 late gestation stillbirths could be prevented if all women avoided going to sleep on their backs from 28 weeks of pregnancy.

When supine sleeping, the weight of the pregnant uterus presses on major blood vessels, decreasing the flow of blood to the uterus and compromising the oxygen supply to the fetus. It is recommended that women settle to sleep on either side for any episode of sleep. As the settling to sleep position is the one held longest during the night, women should not worry if they wake up on their backs. Rather, if they wake up on their back, just roll over back onto their side.

Women should be educated on the importance of side sleeping prior to 28 weeks gestation and this information reinforced during the third trimester of pregnancy.

Read more on side sleeping the Stillbirth Centre of Excellence Research website.

Timing of birth

The recommendation for induced birth must be weighed against the risks of intervention, and respect the woman’s choices, autonomy, and individual care needs. While preventing stillbirth may be an aim of ending pregnancy early, there are associated short and longer term morbidities and developmental consequences for the baby who is born too early, and an increased risk of maternal complications.

The purpose of the Timing of Birth element, in conjunction with all other care elements, is to reduce late-gestation stillbirths without increasing unnecessary intervention and associated maternal and neonatal outcomes.

If there are concerns that may increase the risk of stillbirth, indicating increased monitoring or induction, health care professionals should discuss how these may impact labour, birth, and outcomes, and support the woman in her decision.

Read more on timing of birth the Stillbirth Centre of Excellence Research website.

Measurement strategy

The Safer Baby Bundle has a data collection strategy with key measures that can be used to examine improvement.

Outcome measures

Rate of singleton stillbirths >28 weeks gestation excluding congenital abnormality.

Percentage of women who cease smoking between first antenatal care visit and birth.

Process and performance measures

Element 1 – Smoking Cessation

Percentage of women who have their SFH measurement taken and plotted on growth chart at each antenatal visit from 24 weeks gestation.

Proportion of singleton babies delivered for suspected FGR at 37 weeks gestation or more who have a birthweight >25^th centile (false positive).

Proportion of term births with undetected severe FGR (< 3^rd centile) undelivered at 40 weeks gestation (missed FGR).

Element 2 – Fetal growth

Percentage of women who have their SFH measurement taken and plotted on growth chart at each antenatal visit from 24 weeks gestation.

Proportion of singleton babies delivered for suspected FGR at 37 weeks gestation or more who have a birthweight >25^th centile (false positive).

Proportion of term births with undetected severe FGR (< 3^rd centile) undelivered at 40 weeks gestation (missed FGR).

Element 3 – Decreased fetal movements

Proportion of women provided with DFM education.

Median time from reported DFM to clinical assessment/ presentation to health service.

Element 4 – Side sleeping

Proportion of women who receive education regarding safe going-to-sleep positions.

Element 5 – Timing of birth

Number of women <39 weeks gestation undergoing IOL or elective caesarean section with DFM as only indicator.

Balance measures

Proportion of women with singleton pregnancies who undergo induction of labour or elective caesarean section before 39 weeks gestation.

Percentage of babies admitted to special care nursery after 37 weeks.

Health professional education

Go to the Stillbirth Centre of Excellence Research website:

Continuity of care

Fragmentation of maternity care has been identified as a common issue within the maternity care system. When a pregnant person has many care providers the loss of information and the burden of the individual needing to repeat details to different clinicians can result in sub-optimal care.

Continuity of care is where the individual has a known care provider throughout the antenatal, birthing, and postnatal period, resulting in greater coordination and a strong relationship between the woman and care provider.

This model of care, especially Midwifery Continuity of Care, is associated with more positive health outcomes and greater maternal satisfaction. Increasing access to Midwifery Continuity of Care and reducing overall fragmentation of maternity care is a recommendation of the Safer Baby Bundle.

The ACT Government is committed to over 50% of pregnant people being provided access to this model of care by 2028, as part of the Maternity in Focus System Plan.

Find out more about Maternity in Focus.