Counting for Pregnant Women in Central Sydney Area Health Service

Project Title: Kick Counting for Pregnant Women in Central Sydney Area Health Service

Dr. Tauseefullah Akhund M.B.B.S, MPH (Sydney), (Australia)

1. Which aspect of prevention does your project address?

This project seeks to reduce (if not prevent) infant mortality and in particular stillbirth. The program will monitor the well-being of unborn babies, by increasing women’s awareness of their unborn baby’s movements during the third trimester of pregnancy. Reduced foetal movement is an indicator that an unborn baby may be at risk[1] The project is based on similar programs that have been conducted in Europe with encouraging outcomes. Whilst some stillbirths may be medically unavoidable, many stillborn babies are perfectly formed, with no sign of abnormality. In many cases no cause of death is ever determined, despite thorough post-mortem examinations[2]. European experience in this area suggests that monitoring foetal movement can decrease the incidence of potentially avoidable stillbirths.

2. Briefly describe the background and rationale for the project

Stillbirth is defined as the birth of a baby having achieved 20 weeks gestation and/or 400 grams birth weight, who is born showing no sign of life[3]. Whilst neonatal and infant death rates have declined significantly in the past 10 years, the incidence of stillbirth has remained comparatively high. In 2002 in New South Wales, 515 babies were stillborn[4]. Approximately 1 in every 200 births occurs as stillbirth in pregnancies of 32 weeks gestation and beyond – that is, well beyond the gestational age when a baby is viable if born alive.

Whilst several risk factors have been identified for stillbirth, including maternal smoking, maternal age and obesity[5], these factors are not universally agreed amongst researchers and many babies are stillborn to mothers whose risk is assessed as low[6] . Historically, recording movements of unborn babies has been used internationally as a cheap, accessible monitoring tool. However there is no program currently in existence in NSW that works in partnership with pregnant women and their partners, to monitor their unborn baby’s well-being, thereby increasing the possibility of identifying an unborn baby who may be vulnerable or at risk.

3 Briefly outline the goal and research questions for your project.

The project goal is:

To reduce the incidence of infant mortality within the Central Sydney Area Health Service (CSAHS).

The project research question is:

Will the implementation Kick Counting for Pregnant Women

increase the identification of at risk babies and reduce infant mortality within the CSAHS.?

4. Briefly describe the proposed research methodology

Participants will be recruited to the project through the project partner agencies. Pregnant women and their partners who attend a GP, antenatal clinic or childbirth education classes, will be offered information explaining the project and inviting them to participate. Information about the project will also be provided in Community Health Centres, with people encouraged to pass details of the project on to others in the community.

Women and their partners who wish to participate in the project will be signed up by a designated staff member at the place where they received initial information. The project will be fully explained including the expectations of participants. Admission into the project will be confirmed following a multi-disciplinary assessment that determines the pregnancy to be low risk and the participant’s literacy to be of an appropriate level to participate.

Participants will record their baby’s movements at regular intervals at home during the third trimester of their pregnancy. Their charts will be reviewed at regular antenatal visits.

5. Briefly describe the proposed intervention strategies and supporting theoretical propositions

The Kick Counting project strategies will be to:

· Record unborn babies movements through regular charting, as an indicator of baby’s well-being.

· Increase women’s knowledge and awareness about their body during pregnancy and their baby’s growth and development during pregnancy.

· Promote a multi-disciplinary partnership with pregnant women and their partners, seeking and valuing their contributions and feedback, providing support, encouragement and assistance.

The model from which this project stems is somewhat derived from work in the SIDS area. Disciplines including pathology, infection, physiology and genetics have suggested factors contributing to Sudden Infant Death Syndrome (SIDS), however none have produced definitive causality, despite many years of intensive research. The most definitive work in this area has been in the field of Epidemiology, from which risk factors that relate to babies sleeping environments have been determined. The 2004 8^th International SIDS Conference confirmed that in all countries where statistics are recorded, the reductions in the incidence of SIDS have exceeded 50% (and in some cases up to 90%) since back-sleeping campaigns were introduced world-wide, some ten to fifteen years ago[7]

Why this has worked is not understood, but it has worked. In 1986 there were 207 SIDS deaths recorded in NSW[8]. In 2002, six deaths were attributed to SIDS[9].

Women who have experienced stillbirth often report a sense prior to the event, that “something didn’t feel right”. Quite often she will report that her baby’s movements have reduced. Health care providers often dismiss a woman’s questions, fears or concerns, sometimes to the point of suggesting that she is over-anxious or over-reacting. Norwegian experience found that many mothers whose babies were stillborn waited until no foetal movements had been felt for more than 24 hours before seeking help, indicating a lack of awareness among women of the significance of reduced foetal movement. As previously indicated, European experience suggests that monitoring foetal movement can decrease the incidence of potentially avoidable stillbirths. The approach is cheap, easily accessible and available immediately.

6. What is the target population and setting for your project?
The Central Sydney Area Health Service has one of the highest birthing rates in New South Wales. 6,706 births were recorded in the CSAHS in 2002 and of these, 44 babies were stillborn and 27 babies died in the neonatal period (the first 28 days of life)[10]. This project will target women and their partners who are pregnant or planning to be pregnant. Participants can join the study at the commencement of the third trimester of pregnancy.

7. How will this project contribute new knowledge to the prevention of the problem?

The project does not attempt to reduce the incidence of stillbirth through identifying underlying causes, rather it is a strategy that can be implemented easily, that has the capacity to be effective immediately. If the Kick Counting project leads to more women presenting for care with reduced foetal movements and the infant mortality rate in the CSAHS is subsequently reduced, then the project will be successful.

8. Please list all collaborating organisations

SIDS and Kids NSW
The Feto-Maternal Unit at the Royal Prince Alfred Hospital, Camperdown.

· Antenatal Services , Royal Prince Alfred Hospital

· Division of GPs/Community Health Services, CSAHS

CSAHS Health Promotion Units
NSW Health, Maternal and Perinatal Committee

9.How much funding (excluding GST) would be required for your project?

(Approximate figures are acceptable)

$100,000

References

[1] Froen J. Frederik.,(2004). A Kick from Within – Fetal movement counting and the cancelled progress in antenatal care. Journal Perinatal Medicine, Volume 32, Issue 1, 13-24.

[2] SIDS and Kids (2001) [SIDS and Kids Focussing on Stillbirth: Report from the SOS Pathology Workshop] unpublished report.

[3] SANDS(NSW). (1994) Appropriate Care: for women and their partners when their baby dies. Sydney, Author.

[4] Centre for Epidemiology and Research, NSW Department of Health. New South Wales Mothers and Babies, 2002 . Sydney, NSW Health.

[5] Froen J. Frederik.,(2004). A Kick from Within – Fetal movement counting and the cancelled progress in antenatal care. Journal Perinatal Medicine Volume 32, Issue 1, 13-24

[6] Huang D., Usher, R., Kramer, M., Yang, H., Morin, L., Fretts, R., (2000) Determinants of uexplained antepartum fetal deaths. Obstet Gynaecol, 95, 215-21

[7] Wigfield, R., Fleming, P., Berry, P., Rudd, P., Golding, J(1992) - Can the fall in Avon’s sudden infant death rate be explained by the observed sleeping position changes? British Medical Journal, 304: 282-283

[8] SIDA NSW (1991) Sudden Infant Death Association of NSW, Fifth Annual Report. Sydney, Author

[9] NSW Commission for Children and Young People. (2001) Child Death Review 2002 Annual Report. Sydney, Author.

[10] Centre for Epidemiology and Research, NSW Department of Health. New South Wales Mothers and Babies, 2002 . Sydney, NSW Health.

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