for The Lancet's Stillbirths Series steering committee* Despite increasing attention and investment for maternal, neonatal, and child health, stillbirths remain invisible-not counted in the Millennium Development Goals, nor tracked by the UN, nor in the Global Burden of Disease metrics. At least 2·65 million stillbirths (uncertainty range 2·08 million to 3·79 million) were estimated worldwide in 2008 (≥1000 g birthweight or ≥28 weeks of gestation). 98% of stillbirths occur in low-income and middle-income countries, and numbers vary from 2·0 per 1000 total births in Finland to more than 40 per 1000 total births in Nigeria and Pakistan. Worldwide, 67% of stillbirths occur in rural families, 55% in rural sub-Saharan Africa and south Asia, where skilled birth attendance and caesarean sections are much lower than that for urban births. In total, an estimated 1·19 million (range 0·82 million to 1·97 million) intrapartum stillbirths occur yearly. Most intrapartum stillbirths are associated with obstetric emergencies, whereas antepartum stillbirths are associated with maternal infections and fetal growth restriction. National estimates of causes of stillbirths are scarce, and multiple (>35) classifi cation systems impede international comparison. Immediate data improvements are feasible through household surveys and facility audit, and improvements in vital registration, including specifi c perinatal certifi cates and revised International Classifi cation of Disease codes, are needed. A simple, programme-relevant stillbirth classifi cation that can be used with verbal autopsy would provide a basis for comparable national estimates. A new focus on all deaths around the time of birth is crucial to inform programmatic investment. Why don't stillbirths count?Stillbirths are invisible in many societies and on the worldwide policy agenda, but are very real to families who experience a death. Despite 30 years of attention to child survival interventions, 1,2 more than 20 years of attention to safe motherhood, 3,4 and increasing recent attention to survival of newborn babies, 5-7 the focus worldwide has remained on survival after livebirth. Stillbirths remain mostly ignored, not counting on policy, programme, and investment agendas, both internationally and often also at the national level. 8 The importance of neonatal deaths has risen on the worldwide policy agenda, mainly because of the Millennium Development Goals (MDGs) and recognition of the increasing proportion of child deaths that happen in the fi rst month of life-from 37% in 2000 7 to 41% in 2008. 9 A baby who dies just after birth counts in the MDG tracking, but a baby who dies in the third trimester or even during labour does not. Neither the MDGs nor the Global Burden of Disease metrics mention stillbirths, and stillbirth data are not routinely compiled by the UN. Even when stillbirths are recorded in surveys, the data are frequently combined with early neonatal deaths and reported as perinatal mortality, a combination that reduces visibility and might mask reporti...

Women with a history of prior invasive gynecologic procedures were more likely to develop abnormally invasive placenta. These insights may be used to inform management of pregnancies in women with a history of gynecologic procedures.

Introduction. Abnormally invasive placenta involves abnormal adherence of the placenta to the myometrium and is associated with severe pregnancy complications such as blood transfusion and hysterectomy. Knowledge of outcomes has been limited by small sample sizes and a focus on maternal rather than neonatal outcomes. This study uses population-level data collected over 10 years to investigate maternal and neonatal outcomes and trends in incidence of abnormally invasive placenta (also known as placenta accreta, increta and percreta). Material and methods. A population-based record linkage study was performed, including all women who gave birth in New South Wales, Australia, between 2003 and 2012. Data were obtained from birth records, hospital admissions and deaths registrations. Modified Poisson regression models, adjusted for confounding factors, were used to quantify the effect of abnormally invasive placenta on adverse maternal and neonatal outcomes. Results. Abnormally invasive placenta was significantly associated with morbidity for mothers (adjusted relative risk 17.6, 99% confidence interval 14.5-21.2) and infants (adjusted relative risk 3.1, 99% confidence interval 2.7-3.5). Abnormally invasive placenta increased risk of stillbirth (relative risk 5.4, 99% confidence interval 4.0-7.3) and neonatal death (relative risk 8.0, 99% confidence interval 1.5-41.6). The overall rate of abnormally invasive placenta was 24.8 per 10 000 deliveries, and 22.7 per 10 000 among primiparae. Incidence increased by 30%, from 20.6 to 26.9 per 10 000, over the 10-year study period. Conclusions. Abnormally invasive placenta substantially increases the risk of severe adverse outcomes for mothers and babies, and the incidence is increasing. Delivery should occur in tertiary hospitals equipped with neonatal intensive care units. Clinicians should be cognizant of the risks, particularly to infants, and maintain a high index of suspicion of abnormally invasive placenta, including in primiparae.

BackgroundPediatric admissions to intensive care outside children’s hospitals are generally excluded from registry-based studies. This study compares pediatric admission to specialist pediatric intensive care units (PICU) with pediatric admissions to intensive care units (ICU) in general hospitals in an Australian population.MethodsWe undertook a population-based record linkage cohort study utilizing longitudinally-linked hospital and death data for pediatric hospitalization from New South Wales, Australia, 2010–2013. The study population included all new pediatric, post-neonatal hospital admissions that included time in ICU (excluding neonatal ICU).ResultsOf 498,466 pediatric hospitalizations, 7525 (1.5%) included time in an intensive care unit – 93.7% to PICU and 6.3% to ICU in a general (non-PICU) hospital. Non-PICU admissions were of older children, in rural areas, with shorter stays in ICU, more likely admitted for acute conditions such as asthma, injury or diabetes, and less likely to have chronic conditions, receive continuous ventilatory support, blood transfusion, parenteral nutrition or die.ConclusionsA substantial proportion of children are admitted to ICUs in general hospitals. A comprehensive overview of pediatric ICU admissions includes these admissions and the context of the total hospitalization.

Background:  Deficiencies in investigation and audit of perinatal deaths result in loss of information thereby limiting strategies for future prevention. The Perinatal Society of Australia and New Zealand (PSANZ) developed a clinical practice guideline for perinatal mortality in 2004.Aims:  To determine the current use and views of the PSANZ guideline, focussing on the investigation and audit aspects of the guideline.Methods:  A telephone survey was conducted of lead midwives and doctors working in birth suites of maternity hospitals with over 1000 births per annum in Australia and New Zealand.Results:  Sixty‐nine of the 78 eligible hospitals agreed to participate. A total of 133 clinicians were surveyed. Only 42% of clinicians surveyed were aware of the guideline; more midwives than doctors were aware (53 vs 28%). Of those, only 19% had received training in their use and 33% reported never having referred to them in practice. Implementation of even the key guideline recommendations varied. Seventy per cent of respondents reported regularly attending perinatal mortality audit meetings; midwives were less likely than doctors to attend (59 vs 81%). Almost half (45%) of those surveyed reported never receiving feedback from these meetings. The majority of clinicians surveyed agreed that all parents should be approached for consent to an autopsy examination of the baby; however, most (86%) reported the need for clinician training in counselling parents about autopsy.Conclusions:  Effective implementation programmes are urgently required to address suboptimal uptake of best practice guidelines on perinatal mortality audit in Australia and New Zealand.

Objective To determine whether the disparity gap is closing between stillbirth rates for Indigenous and non-Indigenous women and to identify focal areas for future prevention efforts according to gestational age and geographic location.Design Population-based retrospective cohort study.Setting Queensland, Australia.Population All singleton births of at least 20 weeks of gestation or at least 400 g birthweight. MethodsRoutinely collected data on births were obtained for the period 1995 to 2011. Indigenous and non-Indigenous stillbirth rates and percent reduction in the gap were compared over time and by geographic location and gestational age.Main outcome measures All-cause and cause-specific stillbirth rates (per 1000 ongoing pregnancies).Results Over the study period there was a 57.3% reduction in the disparity gap. Although marked reductions in the gap were shown for women in regional (57.0%) and remote (56.1%) locations, these women remained at increased risk compared with those in urban regions. There was no reduction for term stillbirths. Major conditions contributing to the disparity were maternal conditions (diabetes) (relative risk [RR] 3.78, 95% confidence intervals [95% CI] 2.59-5.51), perinatal infection (RR 3.70, 95% CI 2.54-5.39), spontaneous preterm birth (RR 3.08, 95% CI 2.51-3.77), hypertension (RR 2.22, 95% CI 1.45-3.39), fetal growth restriction (RR 1.78, 95% CI 1.17-2.71) and antepartum haemorrhage (RR 1.58, 95% CI 1.13-2.22). ConclusionsThe gap in stillbirth rates between Indigenous and non-Indigenous women is closing, but Indigenous women continue to be at increased risk due to a number of potentially preventable conditions. There is little change in the gap at term gestational ages.

PVI irrigation after the closure of fascia and before closure of skin is of no benefit in the prevention of SSI in women undergoing CS.

Gallstone disease during pregnancy was associated with adverse maternal and neonatal outcomes. Most women with gallstone disease during pregnancy are managed conservatively. Surgical management was associated with decreased risk of readmission.