Open Access Research Association between reduced ...

1 Association between reduced stillbirthrates in England and regional uptake ofaccreditation training in customisedfetal growth assessmentJason Gardosi,1,2 Sally Giddings,1 Sally Clifford,1 Lynne Wood,1 Andr Francis1To cite:Gardosi J,Giddings S, Clifford S, between reducedstillbirth rates in England andregional uptake ofaccreditation trainingin customised fetal ;3 Prepublication history forthis paper is available view these files pleasevisit the journal online( ).Received 3 September 2013 Revised 27 October 2013 Accepted 27 November 20131 Perinatal Institute,Birmingham, UK2 University of WarwickMedical School, Coventry, UKCorrespondence toProfessor Jason assess the effect that accreditationtraining in fetal growth surveillance and evidence-basedprotocols had on stillbirth rates in England and :Analysis of mortality data from Office ofNational.

2 England and Wales, including three NationalHealth Service (NHS) regions (West Midlands, NorthEast and Yorkshire and the Humber) which between2008 and 2011 implemented training programmes incustomised fetal growth :Live births and stillbirths in England andWales between 2007 and outcome :There was a significant downward trend(p= ) in stillbirth rates between 2007 and 2012 inEngland to , the lowest rate recorded sinceadoption of the current stillbirth definition in 1992. Thisdrop was due to downward trends in each of the threeEnglish regions with high uptake of accreditationtraining, and led in turn to the lowest stillbirth rates onrecord in each of these regions.

3 In contrast, there wasno significant change in stillbirth rates in the remainingEnglish regions and Wales, where uptake of training hadbeen low. The three regions responsible for the recorddrop in national stillbirth rates made up less than aquarter ( ) of all births in England. The fall instillbirth rate was most pronounced in the WestMidlands, which had the most intensive trainingprogramme, from the preceding average baseline in 2000 2007 to in 2012, a 22%drop which is equivalent to 92 fewer deaths a to the whole of the UK, this would amountto over 1000 fewer stillbirths each.

4 A training and accreditation programmein customised fetal growth assessment with evidence-based protocols was associated with a reduction instillbirths in high-uptake areas and resulted in anational drop in stillbirth rates to their lowest level in20 rates in England and Wales haveseen a little change in the past 20 years andare the highest in Western of stillbirths is a governmenttarget,2yet a 2012 survey conducted byTheTimessuggested that most National HealthService (NHS) Trusts which run maternityunits in England have no specific plans inplace to reduce stillbirth recently, two-thirds of stillbirths werecategorised as unexplained4and tended, byimplication, to be considered , our understanding has improvedwith the application of better classificationsystems and customised birth weight percen-tiles.

5 Which identified that most such unex-plained stillbirthshadprecedingintrauterine growth restriction associatedwith placental 8A 2007 confiden-tial enquiry peer review of case notes of nor-mally formed stillbirths with fetal growthrestriction found that 84% had substandardcare and were potentially avoidable withbetter recognition and assessment of intra-uterine is supported bya recent analysis of the West Midlands mater-nity database which reported that growthrestriction was not only the single strongestrisk factor for stillbirth , but that antenatalrecognition and timely delivery can lead tosignificant reduction in and limitations of this study Analysis of national and regional Office ofNational Statistics data helped to avoid randomvariation due to small numbers at unit or Trustlevel and allowed trends to become apparent.

6 Only total figures were available but previousregional subgroup analysis was able to pinpointthe downward trend in stillbirth rates as due tofewer deaths with intrauterine growth restriction. The study was observational but there have beenno other regional or national initiatives whichcould have accounted for the reduction in still-births over this period, suggesting that the asso-ciations observed were J, Giddings S, Clifford S, ;3:e003942. AccessResearchHowever, antenatal detection of fetal growth problemshas been traditionally poor in the NHS, with publishedreports of detection rates ranging from 15% to 24%,11 12and 18% in a 2006 baseline audit in , a major focus of the West Midlands PerinatalInstitute s stillbirth prevention strategy since 2008/2009,supported by the Strategic Health Authority and theregion s Primary Care Trusts, has been to improve theantenatal recognition of growth restriction in low-riskand high-risk pregnancies.

7 The programme was under-pinned by customised charts which are adjustable formaternal constitutional characteristics and predict theoptimal fetal growth curve for each pregnancy( Gestation Related Optimal Weight ,GROW14). Thecharts are used for serial plotting of fundal height andestimated fetal weight measurements, and have beenshowntoincreaseantenataldetectionofi ntrauterinegrowth 17 They also lead to fewer false-positiveassessments and unnecessary ultrasound referrals,15 18thusbeing reassuring for the mother as well as divertingscarce ultrasound resources towards high-risk pregnan-cies, where serial scans are indicated to monitor was instituted from 2008 through a series ofbespoke accreditation workshops with hands-on teachingand assessment.

8 And the promotion of evidence-basedprotocols and best practice 21 The rollingworkshops were offered as a free programme to Trusts inthe West Midlands, and were also held on invitation ininterested Trusts in other wanted to assess the effect that this training pro-gramme had on stillbirth rates , using the latest release ofnational statistics for English regions and training in customised growth assessmentand protocols was conducted in h workshops andcovered: Rationale of fetal growth assessment; National and regional guidelines; Use of GROW software including data entry and printout of chart; training in standardised fundal height measurementand serial plotting; Definition of normal, slow, static and acceleratedgrowth; Referral pathways for further investigation by ultra-sound and Doppler; Risk assessment and protocols for serial scans in high-risk pregnancy.

9 Evaluation through a test with MCQs and shortanswers including accreditation workshops were commencedin 2008 at the West Midlands Perinatal Institute inBirmingham and were attended by midwives and midwifetrainers as well as ultrasonographers and junior and seniorobstetricians. The training was also available to staff fromTrusts in other regions, through central or locally arrangedworkshops. Trusts which had accreditation workshopsduring 2012 were not considered trained in this analysisof pregnancies which delivered up to analysisData on live births and stillbirths were derived from theOffice of National Statistics (ONS) mortality statisticsrelease for 201222and previous releases from data were fully anonymised and includedstillbirths from 24 weeks gestation.

10 stillbirth rates werepresented for single year as well as 3-year movingaverages to smooth out short-termfluctuations and high-light longer term trends. Trend analysis was undertakenusing standard 2trend test with 1 degree of linear regression was used to obtain theslopes for the stillbirth rates of each of trainingEighteen of the 19 maternity units, representing 14 ofthe 15 hospital Trusts in the West Midlands, implemen-ted the GROW software and training programme, andthe fortnightly workshops resulted in over 2000 staffbeing trained between 2008 and 2011. In the whole ofEngland and Wales, staff in 46 of the 148 Trusts ( )received accreditation training , resulting in of allpregnancies during this period being cared for in unitswith trained staff (table 1).