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STILLBIRTH: WHAT STEPS CAN WE TAKE TO REDUCE THE RATE?This project is designed to explore the ways in which the risks of stillbirth can be reduced in developed and developing countries.

Our aims are to:

• Define the term stillbirth and evaluate the difficulties involved in researching stillbirth.

• Compare the incidence of stillbirth in both the developed and developing world.

• Define the causes and risk factors for stillbirth in the developed versus the developing world.

• Outline measures to reduce the risk of stillbirth in the developed and developing world.

This site was made by a group of University of Edinburgh medical students who studied this subject over 10 weeks as part of the SSC . o This website has not been peer reviewed.o We certify that this website is our own work and that we have authorisation to use all the content (e.g. figures / images) in this website.

We give credit to our tutor Dr. Margaret Evans.

• Total Website Word count: 9298• Word count minus Contributions page, References page,

Critical Appraisal Appendix, Information Search Report, Word Version appendix and other sections clearly marked as Appendices: 5677

Featured image is credited to Portraitlady4306, who released it into the public domain.

Introduction

By the time you have read this page, four women worldwide will have given birth to a stillborn baby. That's 2.6 million stillbirths every year. Although the vast majority (98%) of these deaths occur in developing countries, rates are still relatively high in many developed countries.[1]

The UK in fact has one of the worst stillbirth rates in the developed world,[2] ranking 33rd out of 35 developed countries.[3] Despite on-going research into reducing rates in the UK, there are several factors which are inhibiting faster progression. The most significant of these are the lack of a universal classification system for causes of stillbirth, and varying definitions for the term 'stillbirth' itself, both of which lead to difficulties in making valid comparisons between studies.

As well as the more clinical difficulties surrounding this subject, there is also a social aspect of stillbirth which needs to be addressed. A common difficulty in approaching such an emotional topic, and the stigma that consequently gets attached to those affected by it, has contributed to a definite lack of public awareness. This has led to stillbirth often being described as a 'hidden grief.'[4]

Featured image is credited to Portraitlady4306, who released it into the public domain.

Problems Surrounding Stillbirth

Defining StillbirthTroubles defining stillbirth have existed since 1913, when the Proceedings of the Royal Society of Medicine published an article showing that they 'fully realized the difficulty of making a definition which was sufficiently broad and yet scientifically correct.' They settled on a child that measured more than 13

inches and exhibited no signs of life.[5] Whilst capabilities to track pregnancy have now progressed to look specifically at weeks of gestation instead of more broad measurements, it remains difficult to use this to classify stillbirth.

The definition recommended by the World Health Organisation for international comparison of stillbirth is a 'baby born with no signs of life at or after 28 weeks’ gestation.’[6] While this was intended to allow for international comparison, it has struggled to be utilised effectively.

The base definition of stillbirth is the death of a foetus that theoretically should have been mature enough to survive if delivered without complications. This is difficult to specify. In the developing world, stillbirth is unlikely to be able to be defined as a death before 28 weeks gestation as the quality of neonatal intensive care is poor, so survival is unfavourable. A study conducted in Bangladesh emphasised the sharp decrease in survival of a baby born at less than 32 weeks gestation, whilst being born between 32 and 36 weeks dramatically improved survival rates.[7] Moreover, in some developing countries, the gestational age of a baby may prove difficult to predict or be inaccurate; therefore birth weight is often a more reliable method to use.[8]

There are also cultural definitions of stillbirth, especially in the developing world. Some communities believe that a stillborn baby is somehow polluted and therefore very much a taboo. This detachment from a medical perspective impacts data collection as families are less likely to report stillbirth.[9]

In developed countries, the availability of more advanced neonatal health care allows babies younger than 28 weeks gestation to survive outwith the womb. Therefore some countries in the developed world have derived their own definitions, for example the USA, Australia, and New Zealand

regard stillbirth as of 20 weeks.[10] In the UK stillbirth is currently at 24 weeks, reflecting the changes in the abortion law from 28 to 24 weeks. Even still, in January 2014 a private bill was ‘intended to enable registration of a child stillborn before the threshold of a 24 weeks. The definition of stillbirth was to be based on the experience of giving birth’.[11] Perhaps this shows the definition of stillbirth is defiant of a numerical value, but instead requires focus on the situation.

In addition to this, the term perinatal death poses another challenge when measuring stillbirth as some studies have suggested that both stillbirth and early neonatal death not be included in the same category, as they believe that both have different etiological differences.[12]

Ultimately if the definitions used in the developed world were applied globally then rates of stillbirth would be much higher. The challenge to standardise such disparity leaves the definition of stillbirth ambiguous. Unfortunately, this makes producing both an accurate epidemiological reflection and a comparison between developed and developing countries difficult.

Data taken from Aminu M et al.  A systematic review using 142 studies highlights the problem of differential definition for comparing data amongst studies (as seen in pie chart).[13]

Classification SystemsA major problem in the prevention of stillbirth is the absence of a universal protocol and classification system for diagnosis. A classification system is crucial for analysing and evaluating the cause of stillbirth and hence developing an effective strategy for prevention. A variety of classification systems exist, each with their own advantages and disadvantages, however none of them are used in a universal capacity.

A number of studies have found significant variation in the usefulness of the current classification systems. The most widely used of these systems include Extended Wigglesworth, Extended Aberdeen, Tulip, CODAC, PSANZ-PDC and ReCoDe. They differ in their accessibility, quantity of unexplained deaths, inter-observer agreement and their retention of vital information concerning death. These factors result in CODAC being viewed as the strongest all-round classification system that has the potential to be used at a universal scale. However not all studies agree with this and many developed countries refuse to give up their own classification system.[14]

One study has proposed its own diagnostic workup,[15] which is a step forward and would improve data on causes of stillbirth, therefore allowing research progression. However certain barriers may prevent this from being followed through correctly, for example lack of MRI experience with stillborn babies.[15] Therefore other barriers need to be addressed in order for a new system to be successful e.g. additional training.

Another problem with this study is the fact that it cannot be implemented in many developing countries, simply due to a lack of necessary resources. Therefore a universal system is not currently feasible, however progression in this area in both developed and developing countries is needed in order to reduce stillbirths.

Featured image is credited to Stinelk, who released it into the public domain.

 Stillbirth in Developed Countries

IncidenceIn 2011, a study published by the Lancet revealed that ‘the UK had about 4,100 stillbirths in 2009' and, 'with a rate of 3.5 per

1,000 births’.[16] The study aimed to improve estimates of stillbirth in 193 countries as data surrounding stillbirth is still not consistently reported to the World Health Organisation. The UK was ranked 33rd out of 35 high-income countries, reflecting the fact that ‘stillbirth rates in the UK are around the same today as they were in the late 1990s’.[17]

This stagnant situation is despite action by UK development programmes that have led to other improvements such that ‘the number of girls and women dying during pregnancy and childbirth has fallen from 543,000 a year to 287,000’ since 1990'.[18] Perhaps the child-bearing woman is changing. More women are having children at an older age and present with greater risk factors for stillbirth, for example it has been found that there is an increased proportion of obese women in the childbearing population, according to trend data from the Health Survey for England in the period 1993 to 2010.[19] On the other hand, this may reflect the disparity of living conditions within developed countries.

In the UK, stillbirth rates vary widely, for example in the East Midlands rates vary from 1.5-7.9 stillbirths per 1000.[20] The variation present emphasises the potential for improvement. Implementation of this potential has led rates of stillbirths in Norway to decline by 50% in the last 20 years.[2]

To read about causes, click here.

To read about risk factors, click here. 

To conclude, stillbirth is still a significant issue in developed countries. The majority of risk factors, however, are preventable, and future reduction in rates could be achieved with further education and awareness.

Featured image is credited to travelourplanet.com,  licensed under the Creative Commons Attribution 2.0 Generic license.

Causes of Stillbirth in Developed Countries

There are many different causes of stillbirth in the developed world and often the cause cannot be explained. Stillbirth investigation protocols and classification systems vary widely and the lack of a universal procedure creates difficulty comparing and collecting data on the prevalence of each cause.[3] This has been discussed in 'Problems surrounding stillbirth'.

A study from the Lancet series investigated causes of stillbirth in the developed world. The causes found are included below. The classification system used by this study involved three coding levels, which allowed multiple disorders and scenarios to be classified as the cause of death, avoiding attributing death to a single cause which can lead to significant inaccuracy. The study involved six high-income countries all using the same methods. This reduces variation between countries however the small sample size questions whether the results, if extrapolated, would be representative of larger populations.

Causes of stillbirth:• Placental problems• Haemorrhage• Infection• Umbilical cord problems• Medical and pregnancy disorders• Intrapartum deaths• Congenital disorders [3][21]Placental Problems

Placental complications are responsible for a large number of stillbirths either directly or indirectly by causing a problem in growth and development.[21] A problem with blood flow to the

foetus may occur due to thrombosis or infarctions in the placenta,[3] or the placenta may separate from the womb too early (placental abruption).[21] It is often unknown why deterioration of the placenta takes place and it can be difficult to pick up changes at routine checks, therefore current research aims to find out more about placental complications.[22]

Haemorrhage

Fetal maternal haemorrhage before or during labour can cause stillbirths, however it is difficult to estimate the incidence due to a lack of routine screening for this disorder.[3]

Infection

Infection is a major cause of stillbirths, however this may also be underestimated due to lack of investigation.[3] Causes of infection in the developed world include: parovirus B19, group-B streptococcus, Listeria, Escherichia coli, enteroviruses, cytomegalovirus, influenza virus, rubella and herpes simplex. Stillbirths most often occur due to chorioamnionitis and preterm prelabour rupture of membranes (PPROM) as a result of infection.[3][21]

Umbilical cord problems

The umbilical cord may slip down into the womb before the baby is born (cord prolapse) or it may get caught around the baby’s neck, leading to stillbirth.[21]

Medical and pregnancy disorders

A variety of disorders can contribute to stillbirth including: pre-clampsia (a condition causing maternal hypertension), diabetes and intrahepatic cholestasis of pregnancy (liver disorder). [21]

Intrapartum deaths

Stillbirths occurring during labour often involve extremely preterm babies and many causes have antepartum origins .[3]

Congenital disorders

Genetic physical defects in the baby can lead to stillbirth,[21] however there may be and underestimation due to lack of testing and varying classifications.

It has also been suggested that suboptimal care is associated with stillbirths in developed countries, both staff-related (delayed recognition/response, communication failure) and maternal (antenatal care attendance, risk factor control).[3]

Featured image is credited to Nephron, licensed under the Creative Commons Attribution-Share Alike 3.0 license.

Risk Factors for Stillbirth in Developed Countries

Perhaps the most important underlying trait of the risk factors that are present in high income countries is that a large proportion of them could be avoided through individual choice; this has major implications in evaluating the most effective strategies for reducing stillbirth rates.

(Data taken from Flenady V et al. Stillbirths: the way forward in high income countries. Lancet. 2011; 377: 1703-17.) [3]

A 2011 Lancet paper conducted a systematic review of published literature and, using meta-analysis, attempted to identify the most significant contributing factors in increased risk of stillbirth in high-income countries.[23] Strict exclusion criteria and quality assessment by multiple independent parties ensured studies included were of consistently high quality, and the use of a random effects model meant that the results from studies of varied designs and populations could be combined to

produce pooled adjusted odds ratios.

An issue that was, again, acknowledged in this paper was the difficulty in making comparisons between papers that used different definitions of stillbirth. For more information on this, see 'Problems Surrounding Stillbirth.'

Among the key risk factors identified in this paper, three in particular stood out as of most significance, as well as one further factor (alcohol consumption) that has been widely accepted as a risk factor in the majority of literature in this field:

Please click on the following titles to read more.

• Maternal BMI • Smoking• Advanced maternal age• Alcohol consumptionFeatured image is credited to Tomasz Sienicki,  who released it into the public domain.

 Maternal BMI

There are a number of metabolic factors associated with obesity which greatly increase the risk of adverse maternal health outcomes, including:

• Hyperlipidaemia• Vascular endothelial dysfunction• Increased systemic inflammatory responses.[24]  These factors can all lead to hypertension, which has a wide range of potential consequences, including increased chance of pre-eclampsia and placental thrombosis,[25] both of which will significantly increase the chance of stillbirth.

The 2011 Lancet paper found that maternal BMI in both the overweight and obesity categories combined was found to be the highest-ranking modifiable risk factor, with the odds of stillbirth occurrence increasing by 23% and 60% for overweight and obesity categories respectively.[23]

In 2007, a cohort study was conducted to investigate the influence of maternal BMI on foetal and infant death.[25] This provided further evidence to support the theory of high BMI being detrimental to foetal health:

• Obese women had a hugely increased risk of stillbirth, with an adjusted odds ratio of 2.32 (95% CI 1.64-3.28).

• When primary outcome results were plotted on a scatter graph, the continuous relationship between BMI and risk of foetal or infant death showed a V-shaped formation, where women falling closer to underweight or overweight categories had an increasingly high risk of infant or foetal death. The minimum risk was found to be 23 kg/m2, with risk increasing significantly thereafter.

These outcomes showed very little alteration when they were adjusted for bias and confounding using recalculation of primary outcomes in a multivariate model.

Despite a large sample size of 29,856 women and the multivariate approach, the study did have certain limitations:

• Significant factors, such as smoking status and BMI were self-reported, which could have introduced an element of bias into the study.

• Certain factors were not included in the multivariate approach, such as alcohol consumption and quality of antenatal care, both of which have the potential to be confounders.

• Women of advanced maternal age were not excluded from the study, despite it being widely accepted that this increases chance of stillbirth.

9984 women were excluded from the population due to unknown BMI, which could represent a significant proportion of the overall demographic lost, potentially introducing selection bias.

Smoking

Smoking has multiple detrimental effects on foetal development, which can be broadly divided into two categories.

• Intrauterine hypoxia: smoking increases levels of carboxyhaemoglobin in the blood, leading to reduced oxygen transfer from maternal blood supply to that of the foetus. It also causes increased nicotine levels, imitating vasoconstriction and increased vascular resistance, therefore leading to reduced foetal blood flow.[26]

• Nutrient deficiency: smoking increases metabolic rate, therefore can lead to lower calorie availability and reduced foetal grow. Tobacco also causes various deficiencies in nutrients that are fundamental in ensuring normal foetal development, such as vitamin B12, zinc and folate.[27]

In the 2011 Lancet paper a meta-analysis of four studies showed a 36% increase in the odds of stillbirth occurring with any smoking during pregnancy.[25] Whilst this figure was taken from studies based on maternal reporting, which has the potential to introduce both recall and self-reporting bias, it is undoubtedly a figure that indicates smoking as a risk factor that needs to be seriously considered.

A study conducted by Wisborg et al. found that smoking during pregnancy was associated with an increased risk of stillbirth, with an odds ratio of 2.0, however they also found that both stillbirth and infant mortality was comparable between populations of women who had stopped smoking during the first trimester and those who had been non-smokers since conception.[26]

Not only did the study have a large sample population of 25,102, but it also used a multivariate approach to adjust for potential confounders, with conclusions remaining un-altered after the adjustment process. However the study did have its limitations. The data collected was self-reported through the use of questionnaires, which may have introduced bias and potential underestimation of each individual’s smoking. Also, the categories into which women were placed were very broad, with a “smoker” being classified as someone who smoked one or more cigarettes a day; this makes it difficult to draw conclusions about the point at which smoking becomes a definite threat to the life and health of the unborn foetus.

Advanced Maternal Age

The mechanism by which advanced maternal age (usually classified as 35 years or older)[3] increases risk of stillbirth is not fully understood, however placental pathology associated with ageing has been implicated in various studies. For example, sclerotic lesions in myometrial arteries are thought to increase with age, leading to underperfusion and intrauterine hypoxia. Other theories involve the effects of the hormone changes that are associated with ageing on the uterus.[28]

The 2011 Lancet paper found that maternal age of 35 years or older was associated with an increase of 65% in the odds of stillbirth; in addition to this, a linear progression was indicated, implicating a causal relationship between age and risk of stillbirth. Although these findings may not be wholly representative of the majority of high-income countries, being taken from only 5 of the 13 countries included in the study, they are again indicative of a substantial number of stillbirths that could have been prevented.[25]

Alcohol Consumption

Consumption of alcohol whilst pregnant has been shown to have a wide range of disorders associated with it, such as neurodevelopmental problems, facial dysmorphology and impaired growth .[29] As with smoking, intrauterine oxygen deprivation has been implicated, with models suggesting an increase in coagulation factors in the blood and a consequent decrease in blood flow through the placenta. Another theory implicates increased synthesis of prostaglandins, which decrease cell division, thereby leading to impaired growth.[30]

The detrimental effect on pregnancy outcomes due to alcohol consumption is highlighted in a paper that made up part of the Lancet Stillbirth Series 2011.[3] It states that there is an estimated 40% increase in the odds of a stillbirth occurring associated with consumption of alcohol during pregnancy and, despite the risks being widely known by the public, is at least partially responsible for a substantial number of stillbirths every year.

Stillbirth in Developing Countries

IncidenceThe vast majority of stillbirths occur in the developing world, with 98% of approximately 2.6 million stillbirths annually in 2009, taking place in middle- and low-income countries. Southeast Asia and Africa account for 2/3rd of all stillbirths with rural families on these continents accounting for more than half of all stillbirths globally. In some developing countries the rate of stillbirth can be as high as 10 times that of the developed world. Between 1995 and 2009 the global stillbirth decreased by 14% (1.1% yearly, however Africa has not shared the same success with a rate of decline of only 0.7% in this region. [31]

Despite the majority of stillbirths occurring in developing countries the incidence within these regions varies significantly.

Africa is the continent with the highest incidence globally - an average of 28 stillbirths per 1000 births in comparison to approximately 3 per 1000 births in the developed world.[31] A 2009 survey by Save the Children and WHO found that seven out of the ten countries with the highest stillbirth rates were on the African continent as shown in table 1 below. Every country in Africa is in fact ranked within the bottom 65 out of 193 countries for the worst stillbirth rates – a very grave statistic for the continent.[32,33] A women giving birth in Africa has a 24-fold risk of having a stillbirth during labour in comparison to a women in the developed world.[34]

This table shows the stillbirth statistics for the ten countries with the highest stillbirth rates globally.  UK is represented at the bottom of the table as a reference for comparison. Table is authors own with data from.[2]

Click to enlarge table.

The ten countries in table 1 with the highest stillbirth rates represent 1.8 million of all stillbirths globally. The global stillbirth rate of 19 per 1000 births is grossly exceeded by all of the above countries. As can be seen from the table, the country alone that ranks worst out of 193 countries, with an incidence rate of 46.7 stillbirths per 1000 births, equating to 264, 550 stillbirths per year, is Pakistan.[31] This rate is thirteen times higher than that of the UK.

Pakistan’s stillbirth rate can be explained in the same way as the other nine countries within the table. The statistics closely mimic the distribution of maternal death and stillbirth risk factors globally, as a result of poor healthcare infrastructure and lack of pre- and post-natal care. Two-thirds of stillbirths within these countries occur in rural settings where there is a lack of healthcare available for the treatment of obstructed and prolonged labour, pre-eclampsia and maternal infections – all treatable and preventable in the developed world – accounting

for the vast percentage of stillbirths in the developing world. The countries with the highest incidence also closely correlate with statistics on the ratio of trained health care personnel within the country and the maternal mortality index. [31,34,8]

The report by Save the Children proposes that half of all stillbirths globally could be prevented if maternal and neonatal healthcare was available free of charge and at the point of need including access to trained midwives and other health professionals during pregnancy and whilst in childbirth.[33, 8] 1.2 million stillbirths occur during labour when complications arise and obstetric care is critical for the survival of the mother and baby but is not available due to a severe lack of trained healthcare professionals throughout the developing world.[34]

It is possible that figures are in fact even higher than those represented due to under-reporting and lack of data collection. Almost 50% of deliveries in the developing world occur at home in rural settings and no standard protocol for reporting and collating data about stillbirths may exist, therefore many developing countries have little of no data available on the rate or cause of stillbirths.[31,33,34,8]

• To read about causes, click here.

• To read about risk factors, click here.To conclude, in comparison to developed countries, lack of resources is the major barrier to reducing rates of stillbirth in developing countires. In addition to this, a lack of data makes it difficult to assess where future initiatives to reduced stillbirth should be focused. A national survey would be a step in the progression of stillbirth awareness.

Featured image is credited to Bernard Gagnon,  licensed under the Creative Commons Attribution 2.0 Generic license.

Causes of Stillbirth in Developing Countries

98% of stillbirths occur in low-income countries. One of the fundamental reasons behind this is poor obstetric care. However, the individual causes of stillbirths in low income countries have been described as “patchy” due to the difficulty in collecting data. There is a lack of national surveys on stillbirths; currently only Pakistan and Egypt have national assessments of the cause of stillbirths.[35] Furthermore nearly half of births occur in the home meaning that they are often unreported.[8]

Causes of Stillbirth:• Infection• Hypertensive disorders• Prolonged and obstructive labourThese 3 causes were identified as the major causes of stillbirths in developing countries in a paper reviewing English literature from 2003-2008 related to stillbirth and perinatal mortality in developing countries.[8] A review paper is useful as an overview, however, there were no comments on the value of the studies which led to these conclusions being drawn. However, other studies have found similar results.[36][37]

Hypertensive disorders

Pre-eclampsia is a hypertensive disorder which reduces blood flow to the placenta, which can lead to hypoxia of the foetus. [8] With screening, this condition could easily be picked up, and many stillbirths prevented. In a study using women participating in a trial researching the effects of calcium supplements during pregnancy, hypertensive disorders along with spontaneous preterm delivery accounted for the majority of perinatal deaths. However, the value of this finding is limited as the study actually targeted women at high risk of pre-eclampsia. However, the study did find that women receiving calcium had a lower rate of stillbirths due to hypertensive disorders. This highlights a

potential intervention, which is relatively inexpensive and easy, which may improve stillbirth rates.[38]

Infection

There are several ways that infection can lead to stillbirth, such as direct infection, placental damage, or severe maternal illness .[39] A study investigating aetiology of stillbirths in Ghana found that the most common cause of antepartum deaths was maternal disease, of which 72.4% was due to maternal infection,[36] the most important causes being HIV, syphilis and malaria.

As infection can be classified as a cause and a risk factor, it will be discussed further in the risk factor section.

Prolonged and obstructive labour

A prospective observational study researching causes of non-hospital, community-based still births and early neonatal deaths found 20% of stillbirths were due to prolonged labour.[37] The method of verbal autopsy was used which significantly limits the value of the study due to issues with bias. Additionally, the very small sample size increases the effect chance will have on the results. However, collecting data on community still-births is such a difficult task that there are limited other options. A literature review supports the previous studies findings, reporting that 10-25% of stillbirths in developed countries will be due to prolonged and obstructed behaviour.[8] The foetus does not die from prolonged labour itself, rather, from associated asphyxia, trauma and infection due to prolonged labour.[8]

Featured image is credited to DFID- UK Department for International Development,  licenced under the Creative Commons Attribution 2.0 Generic license.

Risk Factors for Stillbirth in Developing Countries

Syphilis   Pregnant women having infections can contribute to their risk of stillbirth. Many studies have recognised maternal Syphilis infection as a risk factor for stillbirth. One retrospective cohort conducted in Tanzania found infection of specifically high-titer active syphilis to have an ARR of 18.1, 95% CI (5.5-59.6.)[40]

The methods of the study were to investigate the delivery outcomes of women with syphilis to controls in three hospitals in the North-West of the country. The study used a questionnaire to determine information such as literacy and sexual behaviour of participants. This may mean that interviewer and recall bias could impact the study. This study is quite weak in the respect that it has a small sample size of 380 women, which increases chance. Moreover, the methods of determining gestational age are dubious, however it should be appreciated that this may be the only way of determining gestational age due to lack of resources.

The study uses various statistical testing in an attempt to eliminate confounding factors and uses multiple tests to ensure that syphilis is diagnosed correctly. A particular strength of the study is its attempts to be representative of the population by the use of two hospitals in the city where treatment is free or a small fee and one in a more rural area to try to minimise selection bias.

The findings have been supported by other studies such as a cohort study investigating risk factors in South America which found Syphilis infection to have an ARR of 2.4, 95% CI (2.1-2.8) for fetal death.[41] A strength of this particular study was the large sample size of 837,232 singleton births which reduced the occurrence of chance. Moreover, the study has clear

exclusion criteria such as unknown gestation age and multiple births. Various statistical analysis tests are used to reduce the impact of confounding factors on results. However, this study was not population-based and did not include data from home births, therefore the conclusions only represent the minority that participated and may have a selection bias.

MalariaMalarial infection and its link to stillbirth is a matter of some controversy amongst researchers. One study in Ethiopia identified that malarial infection could have a seven-fold increase on stillbirth rate.[42] It should be pointed out that this study was not conducted during a malarial epidemic and therefore it is unlikely to reflect the true impact of malaria during an epidemic. Others have challenged these findings and have in fact claimed that malaria infection can have a protective affect on stillbirth chances.

A study in rural Malawi suggested this where they found that perinatal mortality was less in babies of >2500g where there was placental malaria with an odds ratio of 0.35 95% CI (0.14-0.92.)[43] This study however has a small sample size of 2063 women thus chance may have affected results. However, the study has various strengths such excluded women whose data was incomplete or missing, and the use of statistical analysis to reduce confounding factors. The question of whether malaria is a genuine contributor to stillbirth remains open to debate and requires further research.

HIVHIV infection has been discussed as a potential risk factor for stillbirth in the developing world. Leroy V et al. researched HIV infection and pregnancy outcome in Rwanda and found 10/372 HIV positive women and 8/371 HIV negative women had a stillbirth giving a RR of 1.2.[44] This study is small with 364

cases and 365 controls, however has a high participation rate of 95% which reduces selection bias. Such statistics would suggest that the presence of HIV infection accounts for very limited occurrences of stillbirth. Overall, many studies have found HIV infection to be insignificant in relation to stillbirth.

Maternal Socioeconomic DisadvantageMaternal socioeconomic disadvantage has also been identified as a reason for high incidences of stillbirth. For example, one prospective cohort study conducted in 5 resource poor countries and one mid-country (Argentina) found mothers having no formal education to have a RR of 1.6.[45] This study was prospective and therefore recall bias was minimised. Another strength of this study was that staff were trained to collect data in order to keep consistency. An article published in the Lancet series on Stillbirth suggested that socioeconomic factors may be linked to stillbirth in terms of causing chronic stress on the mother and may be linked to the mother receiving poor quality of care.[46]

Lack of Antenatal CareIn the developing countries where there is a clear lack of provision for all aspects of natal care, mothers are at a greater risk of stillbirth. Whilst examining socio-economic factors and the relation to stillbirth, Mavalanker D et al. noted how the attributable risk for stillbirth decreased as the number of antenatal care visits increased, and discussed how less antenatal visits were associated with complications during pregnancy.[47] This was a case-control study linked with surveys that used interview to collect information on the cases and controls. As a consequence, it could mean that interviewer and recall bias may affect results. However, this study considers women from who gave birth in hospital and at home and random selection is used for controls thus decreasing selection bias.

Lack of training of birth attendants and obstetric careA systematic review published in BMC public health that used 21 studies for data abstraction concluded that proper training of birth attendants and obstetric care could reduce stillbirth rates dramatically.[48] The review contained various papers of overall ‘moderate’ quality grade. Papers deemed ‘low grade’ were excluded. Another strength of the review was that a Delphi method was used to agree on the impact of such risk factors on perinatal death. The expert estimation using Delphi method were that skilled birth attendants could decrease intrapartum stillbirth by 25%, basic obstetric care could decrease intrapartum stillbirth by 45% and emergency obstetric care could reduce levels by 75%. The 27 individuals who carried out the Delphi estimation were experts in maternal and fetal health from six WHO regions from various disciplines.

Featured image is credited to Department of Foreign Affairs and Trade,  licensed under the Creative Commons Attribution 2.0 Generic license.

Conclusions

In order to reduce the risk of stillbirth occurring we first need to understand the causes. Despite being a well documented area of research, a lack of universal classification system has led to difficulties in accumulating and comparing data from different studies. Because of this it is difficult to form solid conclusions as to the definitive causes of individual stillbirths. Therefore a major development in reduction of stillbirth would be the initiation of a set list of criteria that could be adapted to different areas based on available resources and demographic data.

Risk factors on the other hand have been well documented with a large number of high quality studies and are generally

understood much more comprehensivly. Strategies to reduce stillbirth should therefore be aimed at overcoming risk factors. Throughout this project we have identified the most significant risk factors for developed and developing countries.

Smoking and  obesity have been identified as significant risk factors in the developed world. Therefore improved targeted education and support are necessary to reduce these and improve stillbirth rates.

In the developing world significant risk factors include lack of ante-natal care, lack of skilled birth attendants and infection. Access to ante-natal care needs to be improved and better training needs to be provided. Screening for infection could also significantly decrease the effect it has stillbirth. However lack of access, money and political issues are barriers to this, which need to be addressed.

A fundamental issue that affects understanding of stillbirth worldwide is the social taboo surrounding it. Only by encouraging those affected by stillbirth to talk about their experiences can we gain a greater understanding of ways is which we can reduce the risk of stillbirth and stop it from being a hidden grief.

Critical Appraisal

Aim

To determine causes and other characteristics of non-hospital, community based still births and early neonatal death in four low-income countries using verbal autopsy. The sample was taken from 38 communities in 4 low-income countries; Guatemala, Democratic republic of Congo, Zambia and Pakistan.

Study design

Prospective observational using standardised verbal autopsy. Data was sent to local physicians to determine cause of death. Data collection was stored in a digital database and transmitted to a coordinating centre. It permitted edits to check inter and intra form consistency. The sample consisted of 252 perinatal deaths. Stillbirth (SB) 134, Early neonatal death (END) 118.

Intervention

To assess the representative nature of the study group, the socio-demographic characteristics of the mothers and health outcomes of infants in the study were compared to those in the same community who did not enrol. Infants delivered in hospital were excluded as a significant reduced chance of perinatal death makes the groups non-comparable for this study. There was no designated control group.

Statistical tests

Data was analysed using SAS software. T-tests and chi squared tests were used to generate P values that reflect the statistical significance of the data.

Main results

• Nearly half of all END occurs in the first postnatal day of life.• Over half were over 2500 grams• Over half of deaths in the first week of life are attributed to

infection.• Only 17% of deaths were due to prematurity• 3% were due to congenital malformation• Prematurity, cord complications and accidents were

considered the cause of death for 5-7% of deaths

• In 12% cause of death could not be determinedStrengths

• Interviewers were trained and the questionnaire standardized to try to reduce interviewer bias.

• Community coordinators  conducted interviews meaning women were more likely to respond openly to questions as they were talking to someone familiar to them.

• A set definition was used to identify cause of death; the condition which is considered to have made the greatest contribution to the death of the foetus or neonate. This decreases variability between physicians.

Weaknesses

• Observational bias may be present within the study due to using local interviewers and physicians that may have local knowledge of medical care and may positively select study subjects.

• Low participation rates might have resulted in a non-participant bias. However, this was reduced by comparing socio-demographic characteristics of participants with non-participants.

• Social taboos may have impacted the cohort of participants. For example, women who are married are more likely to take part than those who are unwed. They’re also more likely to be from a higher social-economic background. This may have resulted in selection bias.

• The use of a questionnaire could have introduced recall bias. However, the influence of this was reduced by conducting interviews within 7 days of the stillbirth occurring.

• The study limits cause of death to one factor therefore underestimating the true complexity of perinatal deaths and skewing the results

• Assessment of effectiveness was based purely on documented success of VA in previous literature but wasn't directly followed up using scientific methods. This means that there was effectively no solid validation of results.

Conclusion

 The study does have a number of limitations, especially the lack of validation which makes it difficult to gauge the effectiveness of verbal autopsy. The small sample size also means that extrapolation of results may not accurately represent the wider population. However, data for community based stillbirths in developing countries is very scarce and therefore despite its limitations, verbal autopsy may be the most effective compromise in these difficult circumstances.

Image author: Nevit Dilmen

Information Search Report

To begin our project we all had a look at the Lancet Series on stillbirth, which gave us an excellent overview of the subject. We decided to split ourselves into two groups, researching stillbirths in developed and developing countries. This was due to variation between the two groups in areas we planned to investigate and we hoped to compare these groups throughout our project. From our initial reading we discovered problems that need to be addressed to reduce the risks of stillbirth rather than a specific information gap. We found that there is a vast amount of information available, however it is difficult to compare data due to significant issues with the classification of stillbirths.

We began by basing our research on the Lancet series. We then proceeded to look at other sources and note if they were primary or secondary sources. We used reviews of stillbirths as a vast area, and then broke it down into single papers to focus on specific areas.

Database searches involved key words directly related to our topic such as: stillbirth, neonatal death, END, preterm delivery,

obesity, smoking, developing world. We entered these keywords into databases, for example Medline, and used skills learnt from the literature research tutorial to explode and focus options, combine searches and introduce limits.

We were able to gain access to full versions of most articles by logging in through the university as an institution, however sometimes this was not possible, which created some difficulties. Some articles could be accessed by members of the group creating accounts on various websites. This meant overall we could access most of the articles we required. A variety of evidence was available to use for our topic including observational studies, questionnaires, case reports, expert opinion and reviews.

Contributions

Eilidh Baird was involved in researching the problems of defining stillbirth with focus on the modern world. She was also responsible for researching incidence in the developed world.Lucy Barr contributed to the problems of classifying stillbirth. She also investigated incidence in the developing world.Lucy Gripper investigated risk factors for stillbirth in the developed world. Lucy helped to write the introduction and conclusion. Lucy also helped format images. Lucy was also responsible for including hyperlinks and formatting the website. Lucy also took part in referencing.Indira Kenyon was responsible for researching causes in the developing world. She also was responsible for organising the critical appraisal and formatted images to be included in pages. Indira was involved with references, identifying what type of reference they were.Louise Lynch contributed to the problems defining stillbirth with particular reference to the developing world. She was also responsible for investigating risk factors in the developing world. Louise also made the contributions page. Louise also helped format images. Louise was involved with ordering references.Rebecca Price contributed to the problems classifying stillbirth. She was also responsible for looking into the causes of stillbirth in the developed world. Rebecca also helped to write the introduction and conclusion. Rebecca wrote the

information search report and helped order references. 

Everyone wrote the critical appraisal together, aims and objectives, and weekly diary.

References

1. The Lancet. Stillbirths Executive Summary. [internet]. 2011 [cited 2014 October 16]. Available at: http://www.thelancet.com/series/stillbirth.  (Website)

2. Stillbirth: How often does it happen? [internet]. 2014 [cited 2014 October 16]. Available at: https://www.uk-sands.org/why-babies-die/explaining-stillbirth/how-often-does-it-happen. (Website)

3. V Flenady et al. Stillbirths: the way forward in high-income countries. The Lancet [internet]. 2011 April 14 [cited 2014 October 16]; 377(9778): 1703-1717. doi:10.1016/S0140-6736(11)60064-0. (Review article)

4. Scott J. Stillbirths: breaking the silence of a hidden grief. The Lancet [internet]. 2011 April 14 [cited 2014 October 16]; 377(9775): 1386-1388. doi:10.1016/S0140-6736(11)60107-4. (Review article)

5. Definition of Stillbirth. Proceedings of the Royal Society of Medicine1913;6(Obstet Gynaecol Sect):64.  (Report)

6. Who.int. WHO | Stillbirths [Internet]. 2014 [cited 20 November 2014]. Available from: http://www.who.int/maternal_child_adolescent/epidemiology/stillbirth/en/ (Website)

7. Yasmin Sohely, Osrin David, Paul Elizabeth, Costello Anthony. Neonatal mortality of low-birth-weight infants in Bangladesh. Bull World Health Organ  [serial on the Internet]. 2001  July [cited  2014  Nov  20] ;  79( 7 ): 608-614. Available from: http://www.scielosp.org/scielo.php?script=sci_arttext&pid=S0042-96862001000700005&lng=en.  http://dx.doi.org/10.1590/S0042-96862001000700005. (Primary research paper)

8. McClure E, Saleem S, Pasha O, Goldenberg R. Stillbirth in developing countries: a review of causes, risk factors and prevention strategies. J Matern Fetal Neonatal Med. 2009;22(3):183-190.  (Review article)

9. Lawn J, Gravett M, Nunes T, Rubens C, Stanton C. Global report on preterm birth and stillbirth (1 of 7): definitions, description of the burden and opportunities to improve data. BMC Pregnancy and Childbirth. 2010;10(Suppl 1):S1. (Review article)

10. Stillbirthfoundation.org.au, (2014). About stillbirth | Stillbirth Foundation Australia. [online] Available at: http://www.stillbirthfoundation.org.au/about-stillbirth/ [Accessed 19 Nov. 2014]. (Website)

11. Fairbairn C. Registration of Stillbirth. UK: House of Commons; 2014 p. 1-4. (Report)

12. Kramer M, Lui S, Luo Z, Yuan H, Platt R, Joseph K. Analysis of Perinatal Mortality and Its Components: Time for a Change?. American Journal of Epidemiology. 2002;156(6):493-497. (Review article)

13. Aminu M, Unkels R, Mdegela M, Utz B, Adaji S, van den Broek N. Causes of and factors associated with stillbirth in low- and middle-income countries: a systematic literature review.

BJOG: Int J Obstet Gy. 2014;121:141-153. (Review article)

14. V Flenday et al. An evaluation of classification systems for stillbirth. BMC Pregnancy and Childbirth [internet]. 2009 June 9 [cited 2014 November 17]; 9(24): 1-13. doi:10.1186/1471-2393-9-24. (Primary research paper)

15. FJ Korteweg et al. Evaluation of 1025 fetal deaths: proposed diagnostic workup. Am J Obstet Gyneco [internet]. 2012 January [cited 2014 November 17]; 206(1): 53.e1–53.e12. doi:10.1016/j.ajog.2011.10.026. (Primary research paper)

16. BBC, Neil Bowdler. UK stillbirth rates among highest of rich nations. [internet]. 2011 April 14 [cited 2014 Oct 31]. Available at: http://www.bbc.co.uk/news/health-13068789. (Website)

17. SANDS. Research. [internet]. 2014 [cited 2014 Oct 31]. Available at: https://www.uk-sands.org/research. (Website)

18. Gov.uk. Improving the health of poor people in developing countries. [internet]. 2014 September 1 [cited 2014 Oct 31]. Available at: https://www.gov.uk/government/policies/improving-the-health-of-poor-people-in-developing-countries. (Website)

19. Public Health England. About obesity: trends in the UK. [internet]. 2014 [cited 2014 Oct 31]. Available at: http://www.noo.org.uk/NOO_about_obesity/maternal_obesity/uk_trends. (Website)

20. Natalie Cantillon. East Midlands stillbirth report. [internet]. 2011 August [cited 2014 Oct 31]. Available at: http://www.empho.org.uk/Download/Public/12583/1/Stillbirth%20Report%20090911.pdf  (Report)

21. NHS. Stillbirth – causes. [internet]. 2013 Feb 22 [cited 2014 Oct 31]. Available at: http://www.nhs.uk/Conditions/Stillbirth/Pages/Causes.aspx. (Website)

22. SANDS. Stillbirth: Causes. [internet]. 2014 [2014 Oct 31]. Available at: https://www.uk-sands.org/why-babies-die/explaining-stillbirth/possible-causes.  (Website)

23. Flenady V et al. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. The Lancet. 2011; 377: 1331-1340. (Review article)

24. Aune D et al. Maternal Body Mass Index and the Risk of Fetal Death, Stillbirth, and Infant Death: A Systematic Review and Meta-analysis. JAMA. 2014; 311 (15): 1536-1546. (26) (Review article)

25. Tennant P, Rankin J and Bell R. Maternal body mass index and the risk of fetal and infant death: a cohort study from the North of England. Human Reproduction. 2011; 26 (6): 1501-1511. (Primary research paper)

26. Wisborg K et al. Exposure to Tobacco Smoke in Utero and the Risk of Stillbirth and Death in the First Year of Life. American Journal of Epidemiology. 2001; 154 (4): 322-327. (Primary research paper)

27. Institute of Medicine Food and Nutrition Board. Nutrition during Pregnancy: Part I, Weight Gain, Part II, Nutrient Supplements. National Academy Press; 1990. pp. 392-394. (30) (Book)

28 . Waldenstrom U et al. Adverse Pregnancy Outcomes

Related to Advanced Maternal Age Compared With Smoking and Being Overweight. Obstetrics and Gynecology. 2014; 123 (1): 104-112. (33) (Primary study)

29. Bailey B and Sokol R. Prenatal Alcohol Exposure and Miscarriage, Stillbirth, Preterm Delivery, and Sudden Infant Death Syndrome. Alcohol Research and Health. 2011; 34 (1): 86-91. (35) (Review)

30. Kesmodel U et al. Moderate Alcohol Intake during Pregnancy and the Risk of Stillbirth and Death in the First Year of Life. American Journal of Epidemiology. 2002; 155 (4): 305-311. (Review)

31. WHO. Maternal, newborn, child and adolescent health – stillbirths. URL: http://www.who.int/maternal_child_adolescent/epidemiology/stillbirth/en/ (Accessed 05/11/2014). (38) (Website)

32. WHO and Save the Children. Country stillbirth rates per 1000 total births for 2009. URL: http://www.who.int/pmnch/media/news/2011/stillbirths_countryrates.pdf (Accessed 05/11/2014). (Website)

33. Save the Children. Surviving the first day. URL: http://www.savethechildren.org.uk/sites/default/files/images/State_of_World_Mothers_2013.pdf (Accessed 05/11/2014). (Website)

34. The Partnership for Maternal, Newborn and Child Health Factsheet – Stillbirth. URL: http://www.who.int/pmnch/media/press_materials/fs/201106_stillbirths/en/ (Accessed 01/11/2014). (Website)

35. Lawn JE, Yakoob MY, Haws RA, Soomro T, Darmstadt

GL, Bhutta ZA. 3.2 million stillbirths: epidemiology and overview of the evidence review. BMC Pregnancy and Childbirth. 2009; 9(2). doi:10.1186/1471-2393-9-S1-S2 (43) (Review)

36. Edmond KA, Quigley MA, Zandoh C, Danso S, Hurt C, Agyei SO, Kirkwood BR. Aetiology of stillbirths and neonatal deaths in rural Ghana: implications for health programming in developing countries. Paediatric and Perinatal Epidemiology. 2008; 22(5): 430-437. (45) (Primary Study)

37. Engman C, Garces A, Jehan I, Ditekemena J, Phiri M, Mazariegos M, Chomba E, Pasha O, Tshefu A, McClure EM, Thorsten V, Chakraborty H, Goldenberg RL, Bose C, Carlo WA, Wright LL. Causes of community stillbirths and early neonatal deaths in low-income countries using verbal autopsy: an International, Multicenter Study. Journal of Perinatology. 2012; 32:585-592. (Primary study)

38. Ngoc NTN, Merialdi M, Abdel-Aleem H, Carroli G, Purwar M, Zavaleta N, Campodonico L, Ali MM, Hofmeyr GJ, Mathai M, Lincetto O, Villar J. Causes of stillbirths and early neonatal deaths: data from 7993 pregnancies in six developing countries. Bulletin of the health world organisation.  (Review)

39. Goldenberg RL, Thompson C. The infectious origins of stillbirth. American Journal of Obstetrics and Gynecology. 2003;189(3): 861-873. (Review)

40. Watson‐Jones D, Changalucha J, Gumodoka B, Weiss H, Rusizoka M, Ndeki L et al. Syphilis in Pregnancy in Tanzania. I. Impact of Maternal Syphilis on Outcome of Pregnancy. The Journal of Infectious Diseases. 2002;186(7):940-947. (49) (Primary study)

41. Conde-Agudelo A, Belizan J, Diaz-Rossello J.

Epidemiology of fetal death in Latin America. Acta Obstetricia et Gynecologica Scandinavica. 2000;79(5):371-378.  (Primary study)

42. Newman R, Hailemariam A, Jimma D, Degifie A, Kebede D, Rietveld A et al. Burden of Malaria during Pregnancy in Areas of Stable and Unstable Transmission in Ethiopia during a Nonepidemic Year. The Journal of Infectious Diseases. 2003;187(11):1765-1772. (Primary study)

43. McDermott J, Wirima J, Steketee R, Breman J, Heymann D. The effect of Placental Malaria Infection on Perinatal Mortality in Rural Malawi. The American Journal of Tropical Disease and Hygiene. 1996; 55(1): 61-65. (Primary study)

44. Leroy V, Ladner J, Nyiraziraje M, De Clercq A, Bazubagira A, Van de Perre P et al. Effect of HIV-1 infection on pregnancy outcome in women in Kigali, Rwanda, 1992–1994. AIDS. 1998;12(6):643-650. (Primary study)

45. McClure E, Wright L, Goldenberg R, Goudar S, Mohapatra A, Jehan I et al. A prospective study of stillbirths in developing countries. American Journal of Obstetrics and Gynecology. 2006;195(6):S220. (Primary study)

46. Cnattingius S, Stephansson O. The challenges of reducing risk factors for stillbirths. The Lancet. 2011;377(9774):1294-1295. (Review)

47. Mavalankar DV, Trivedi CR, Gray RH. Levels and risk factors for perinatal mortality in Ahmedabad, India. Indian J Pediatr. 1991;58(6):820-820. (Primary study)

48. Yakoob M, Ali M, Ali M, Imdad A, Lawn J, Van Den Broek N et al. The effect of providing skilled birth attendance and

emergency obstetric care in preventing stillbirths. BMC Public Health. 2011;11(Suppl 3):S7. (Review)

Weekly Diary

Week 1 - 24.9.14

• Our first meeting with our tutor was an introductory meeting to get to know each other and find out more about the project. Our tutor gave us lots of useful information about stillbirth and suggested some articles and various ways of approaching the topic.

• We decided that throughout the project comparisons will be made between developed and developing countries. We each took an area to research over the week and planned to have a discussion at our next meeting to enable everyone to have a good overview of the subject.

• Other tasks involved setting up our wordpress website and reading the study guide before our meeting the following Monday.

Week 2 - 29.9.14

• We began our second meeting by briefly discussing our research on stillbirth from the previous week. This ensured that each member of the group had a basic understanding of the topic, mainly in terms of the public health issues surrounding it in both developed and non-developed countries. Again, our tutor was able to expand on any points we were uncertain of and channel our discussions towards the most relevant issues for the project.

• Our focus this week was to begin developing our critical appraisal skills, and we began discussing aspects of research and clinical studies surrounding stillbirth specifically that could be improved. The most universal problem seemed to be that there are many different classification systems for defining the cause of stillbirth,

making comparisons between different clinical studies difficult. This is an area that we agreed needed to be considered when doing our critical appraisals, and so was something we would research individually over the week in order to gain a more comprehensive understanding of it.

• Alongside this, our targets over the next week are to each find a clinical study on a risk factor for stillbirth and to attempt a basic critical appraisal of it.

Week 3 - 6.10.14

• Unfortunately we could not meet with our tutor this week due to work commitments so we all agreed that our following meeting should be longer to counteract for this. We felt  that, having now done background research on stillbirth, it would be a good use of our time  to set objectives as to what areas we felt were important to cover in our project. Therefore, this week we all thought of crucial areas to focus on and collaborated these to form the following list:

• Define the term stillbirth and evaluate the difficulties involved in researching stillbirth.

• Compare the incidence of stillbirth in both the developed and developing world.

• Define the causes and risk factors for stillbirth in the developed versus the developing world.

• Outline measures to reduce the risk of stillbirth in the developed and developing world.

Week 4 - 13.10.14

• We had a really good meeting, as an entire group, with our tutor today. With a new idea of key areas to explore, we were able to move from broader research to look at the literature.

• In preparation for the meeting we allocated half of the group to look into the developed world and the other half the developing. Then, we each chose an article to critically appraise and present to the group. There was a great

mixture of topic area, study type and strength of study shared. This made for interesting comparisons and an overall helpful introduction in how to approach critically appraising literature. The new depth of knowledge gained also led us to approach answering the objectives of our project.

Week 5 - 20.10.14

• We began our fifth meeting by feeding back to our tutor on the work we had done in the previous week. We showed her our first draft of our introduction, and she gave us advice on what she thought could be improved.

• We briefly discussed how we had found writing up our critical appraisals and it was agreed that for next week we would write a few sentences summarising our articles, so that it would be easier when writing the website to bring together all the information we had found of stillbirths.

• We went on to discuss the coding system and what definition to use for stillbirth as there are many used in different countries. We agreed that a member of the group would research into the coding system.

• For next week, we additionally agreed we would redraft our introduction and all read around and find possible articles for the group critical appraisal for our website.

Week 6 - 27.10.14

• We had a productive meeting today with all group members present, but unfortunately not our tutor. We began by discussing the papers we had read up on last week. We also discussed the coding paper suggested by our tutor.

• We discussed the definition of stillbirth, researched and written up by two group members. It was decided that it was most appropriate to put this section at the start of the wiki.

• We had a look at last years wiki's and decided on a possible layout for our own wiki with sections and subsections provisionally decided.

• For this week we will  research a subsection each within the developing or developed world and present at next weeks meeting for discussion.

Week 7 - 03.11.14

• In this week's meeting we reviewed the sections written by each group member. Although they will need some editing we are planning to first write a draft of the critical appraisal, before making amendments to the website.

• We also picked a paper for the final critical appraisal: "Causes of community stillbirths and early neonatal deaths in low-income countries using verbal autopsy: an International, Multicenter Study" by Engmann et al. We felt this paper would have a number of interesting points to discuss.

• For next week's meeting we have planned for everyone to have read the paper through and drawn up a list of strengths and weaknesses of the study. We hope to get a first draft written up in the meeting, which can then be refined over subsequent weeks.

• We are all pleased with the group's current progress; although nothing is in it's final form we have managed to complete a rough draft of the website content, leaving ample time to perfect it.

Week 8 - 10.11.14

•  After having each bullet pointed issues to raise with our group critical appraisal paper, we all met to collaborate our points to form a skeleton draft of our critical appraisal.

• We decided that we should include more literature analysis on each section we have written individually and have agreed to re-write each of our sections with such information for next week.

• Everyone has taken certain areas of the group critical appraisal to re-write into better English.

• Becky has volunteered to write the search report for next week.

Week 9 - 17.11.14

• We combined everyones work for the critical appraisal and finalised it. This was uploaded along with the information search report.

• We then started checking each section of the website and bringing it all together by adding pictures and linking pages together.

• Our for the following week is to create more visual aids for the website such as graphs and finalise each section.

• Our plan is to completely finish the website at our meeting next week.

Week 10- 24.11.14

• This week we reviewed the final website by reading through the individual sections, organising references and inserting tables, graphs and pictures.

• We are planning on proof-reading the website this week and making any last adjustments before submitting.