A New Zealand-led international study published today provides the strongest evidence yet that women can more than halve their risk of stillbirth by going to sleep on either side during the last three months of pregnancy. This mega study (known as individual participant data meta-analysis) has also confirmed the risk of stillbirth associated with sleeping on the back applies to all pregnant women in the last trimester of pregnancy.

Risk factors

In New Zealand, stillbirth is defined as the loss of a baby after 20 weeks of pregnancy. An estimated 2.64 million babies die before birth globally each year, and around 300 babies are stillborn in Aotearoa New Zealand each year. About one in every 500 women in New Zealand will experience the tragedy of a late stillbirth and lose their baby during or after 28 weeks of pregnancy. We have analysed all available data worldwide from five previous studies, including our earlier research, the 2011 Auckland Stillbirth Study, which first identified a link between mothers’ sleeping position and stillbirth risk. The main finding in the mega study, which included information from 851 bereaved mothers and 2,257 women with ongoing pregnancies, was that going to sleep lying on the back (supine) from 28 weeks of pregnancy increased the risk of stillbirth 2.6 times. This heightened risk occurred regardless of the other known risk factors for stillbirth. However, the risk is additive, meaning that going to sleep on the back adds to other stillbirth risk factors, for example, a baby who is growing poorly in the womb. Existing common risk factors for late stillbirth are not easily modifiable. They include advanced maternal age (over 40), obesity, continued cigarette smoking and an unborn baby that is growing poorly, especially if the poor growth is not recognised before birth. Women also have a higher risk during their first pregnancy, or if they have already had three or more babies. Women of Pacific and South Asian ethnicity also have an elevated risk of late stillbirth, compared with European women. If modifiable risk factors can be identified, some of these baby deaths could be prevented. Importantly, our mega study has shown that if every pregnant woman went to sleep lying on her side after 28 weeks of pregnancy, approximately 6% of late stillbirths could be prevented. This could save the lives of about 153,000 babies each year worldwide.

Reduced blood flow

The relationship between the mother going to sleep lying on her back and stillbirth is biologically plausible. A supine position in late pregnancy is associated with reduced blood flow to the womb. Hence, women in labour and women having a caesarean section are routinely tilted onto their side to improve blood supply to the baby. Recent research carried out at the University of Auckland has provided sophisticated evidence about how the mothers’ position influences blood flow. Results obtained using Magnetic Resonance Imaging (MRI) demonstrate the major vessel in the mother’s abdomen, the inferior vena cava, being compressed by the pregnant womb when she is lying on her back. This reduces flow through this vessel by 80%.

Although the mother’s circulation responds by increasing the flow through other veins, this does not fully compensate. The mother’s aorta, the main artery which carries oxygen-rich blood from her heart, is also partly compressed when the mother lies on her back. This decreases blood flow to the pregnant uterus, placenta and baby. We speculate that while healthy unborn babies can compensate for the reduced blood supply, babies that are unwell or vulnerable for some other reason may not cope. For example, our mega study showed that the risk of stillbirth after 28 weeks of pregnancy is increased approximately 16 times if a mother goes to sleep lying on her back and also is pregnant with a very small baby.

What to do

New Zealand research has shown that pregnant women can change their sleeping position. In a recent survey conducted in pregnant women from south Auckland, a community that has a high rate of stillbirth, more than 80% of women surveyed stated that they could change the position they went to sleep in with little difficulty if it was best for their baby. Our advice to pregnant women from 28 weeks of pregnancy is to settle to sleep on their side to reduce the risk of stillbirth, and to start every sleep, including day-time naps, on the side. It does not matter which side. It is common to wake up on the back, but we recommend that if this happens, women should simply roll back on to either side. Lesley McCowan, Professor, Obstetrics & Gynecology, University of Auckland and Robin Cronin, Midwife researcher, University of Auckland This article is republished from The Conversation under a Creative Commons license. Read the original article.

Abortion is a common experience for Australian women. Around one in six have had an abortion by their mid-30s, according our new research published today in the Australia New Zealand Journal of Public Health. Narratives about abortion often stigmatise women who have had one or seek access to one. But our research shows women from all walks of life may have an abortion: married, single, child-free, and mothers. In fact, women who have already had children are more likely to have a termination than those who haven’t. Women make decisions about whether or not to have an abortion in the context of their complex lives. And it’s by no means an easy decision. Our research investigated the factors associated with abortion as women move from their late teens into their mid-30s. We found women with lower levels of control over their reproductive health, whether through family violence, drug use or ineffective contraception, are more likely than their peers to terminate a pregnancy. If we want to reduce the rate of unintended pregnancies and abortion in Australia, we need to empower women to have control over their fertility and support them with appropriate health services.

Women’s experiences

We used data from five surveys of the Australian Longitudinal Study on Women’s Health to examine factors associated with “induced” abortions which were not undertaken because of a foetal abnormality. We looked at a cohort of more than 9,000 women born between 1973-78 who were first surveyed at ages 18-23 years. At the fifth survey they were aged 31-36 years. Overall, by their mid-30s, 16% of the women in this study had reported at least one abortion. We also looked at the proportion of women who reported a new abortion at each survey. At the first survey, when women were aged 18-23, 7% reported having had an abortion. In subsequent surveys, 2-3% of women reported having an abortion since the last survey. While most women reported only one new abortion, around one in ten reported two abortions, and around 2% reported three abortions. Abortion is understandably more common for women when they are in their 20s than it is when women reach their 30s. This may be because many women in their 30s are actively trying to be pregnant, or may be using contraception more effectively if they’re trying to avoid becoming pregnant. Compared with married women, those who were in a de facto relationship, were single, or divorced were more likely to have had an abortion. Women with children were more likely to have an abortion than women who did not have children. In the fourth survey, the majority of women (72%) said they hoped to have one or two children, 20% wanted three or more, while 8% didn’t want to have children. Perhaps unsurprisingly, women who had an abortion in the later surveys were more likely to have previously reported using ineffective contraception, or to have had a past abortion, than women who didn’t terminate a pregnancy in their 30s. Women whose alcohol use had recently become riskier and women who reported using any illicit drugs in the past 12 months were also more likely to have an abortion. Violence was also a big factor. Women who recently experienced partner violence were more likely to terminate a pregnancy than women who reported no violence. Even women who reported childhood sexual abuse had a significantly increased likelihood of abortion in their twenties (but not in their 30s). In fact, women reporting violence of any kind, and at any time, had a significantly increased likelihood of having an abortion.

What can we do about it?

Australia is going through a much-needed process of law reform to ensure women across the country have access to abortions as part their women’s health service. Queensland is the most recent state to remove abortion from the criminal code. Alongside this, we need to improve training and resources to for health providers to identify and help women who may be at risk of unintended pregnancy, particularly those who are using illicit drugs or are experiencing partner violence. We need better ways of reaching all vulnerable women, but especially young women experiencing reproductive coercion. We also need to ensure that all women are provided with good access to information about effective contraceptive choices. While the oral contraceptive pill and condoms are the most common methods Australian women use, long-acting reversible methods (such as intra-uterine devices and implants) can be good options for many women wanting effective contraception.

- Jayne Lucke, Chair, Australian Research Centre in Sex, Health & Society, La Trobe University and Angela Taft, Professor and Director, La Trobe University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Based on an interview with Associate Professor Kirsten Black and Clinical Associate Professor Deborah Bateson conducted at the Annual Women’s and Children’s Health Update, Sydney in February 2018. "Heavy menstrual bleeding" is the new term for menorrhagia. This under-treated condition is easy to screen for in general practice. And screening for it is important as, apart from the discomfort, inconvenience, disturbed sleep, embarrassment and expense heavy menstrual bleeding causes, it is a major cause of iron deficiency in women. Common causes of heavy menstrual bleeding include hormonal variations relating to menarche and menopause, polycystic ovarian syndrome, polyps, fibroids and coagulation disorders. Identifying heavy menstrual bleeding initially involves discussing menstrual patterns with patients, as the diagnosis relies on the subjective experience of the woman as it affects her physical, emotional, social and/or material quality of life. Women may be unsure whether their periods are abnormally heavy compared with other women.  Questions that may assist in the diagnosis of  heavy menstrual bleeding include asking whether a woman needs to wear both a pad and a tampon simultaneously to prevent leakage, whether she has to use super pads and/or tampons and needs to change them every three hours or less, , whether she is concerned about flooding or staining during the day and avoids social activities as a result, whether she regularly takes time off work at the time of her period, whether she has to get up several times overnight to change her pad or tampon, whether she frequently passes clots (often this is associated with significant period pain), and finally, how the issue is affecting her quality of life. It is also important to inquire about associated symptoms such as pain, bloating and feelings of pressure on the bladder or bowel.Investigations usually include iron studies, a full blood count and a pelvic ultrasound. Ideally the ultrasound should be transvaginal as well as transabdominal. Also, ideally the ultrasound should be conducted between days five to 10 of the menstrual cycle, as this is when the uterine lining is less echogenic and scanning at this time reduces the chance of missing lesions such as polyps, within the uterine cavity. It should be noted that heavy menstrual bleeding may be a symptom of malignancy, especially in women over the age of 45 years. Other more specialised tests may also be indicated, such as coagulation studies, if there is suggestion of a bleeding diathesis. Once malignancy has been excluded as a cause of the bleeding, management usually includes hormonal control of the ovulation cycle, such as with the combined oral contraceptives. These reduce bleeding by 30%. An excellent alternative is the hormonal intrauterine system (Mirena^®). If the woman prefers not to use such methods and is not at risk of pregnancy, tranexamic acid or norethisterone, 5mg three times daily, from days five to 26 of the menstrual cycle, can be used. NSAIDS such as mefenamic acid are most effective if commenced just prior to the onset of bleeding and continued into the first few days. Surgical management of heavy menstrual bleeding is usually indicated for women who have completed their families. The less invasive options include endometrial ablation and embolisation of fibroids. Hysterectomy is generally reserved for women in whom less invasive treatments have been unsuccessful, where there is a particular indication (such as large fibroids causing pressure symptoms) or less commonly, at the woman’s request.