Introduction: Stillbirth is a significant global public health issue, with approximately 98% occurring in low- and middle-income countries. The Solomon Islands is a Pacific nation with poor perinatal outcomes and very little previous research investigating stillbirth. Methods: We conducted a retrospective cohort study investigating all stillbirths at the National Referral Hospital in Honiara, Solomon Islands, between January 2017 and December 2018. Causes of stillbirth and risk factors were classified on review of available case files. Results: Over two years, there were 341 stillbirths and 11,056 total births at the National Referral Hospital (30.8 stillbirths per 1000 births). Cause of death was documented for 198 and 142 full case files were available. Most stillbirths occurred antenatally (n=170/198) and 62% were at preterm gestations (<37 weeks). Low birthweight (<2500g) was present in 59% (n=84/142) and preventable maternal conditions, including hypertensive disorders and syphilis, were present in 42% (n=59/142) of cases. Acute events caused 46% of intrapartum deaths and 92% of these had inadequate intrapartum monitoring. Conclusion: Our study is the first to investigate causes of stillbirth in the Solomon Islands. We found a large proportion of preventable stillbirths and significant gaps in documentation. This highlights the importance and feasibility of a national registry. There is an urgent need for targeted training in data collection, improved quality of antenatal and intrapartum care and community awareness to reduce preventable stillbirths in the Asia-Pacific.

Objective: Many growth charts provide single centile cutoffs for each week of gestation, yet fetuses gain weight throughout the week. We aimed to assess whether using a single centile per week distorts the proportion of infants classified as small and their risk of stillbirth across the week. Design: Retrospective cohort study. Setting: Victoria, Australia. Population: Singleton, non-anomalous infants born from 2005-2015 (529,261). Methods: We applied growth charts to identify small-for-gestational-age (SGA) fetuses on week-based charts (single centile per gestational week) and day-based charts (centile per gestational day). Main outcome measures: Proportions <10th centile by each chart, and stillbirth risk amongst SGA infants. Results: Using week-based charts, 12.1% of infants born on the first day of a gestational week were SGA, but only 7.8% on the final day; ie. an infant born at the end of the week was 44% less likely to be classed as SGA (p<0.0001). The relative risk of stillbirth amongst SGA infants born on the final day of the week compared with the first was 1.47 (95%CI 1.09-2.00, p=0.01). Using day charts, SGA proportions were similar and stillbirth risk equal between the beginning and end of the week (9.5% vs 9.9%). Conclusions: Growth standards using a single cutoff for a gestational week overestimate the proportion of infants that are small at the beginning of the week and underestimate the proportion at the end. This distorts the risk of stillbirth amongst SGA infants based on when in the week an infant is born. Day-based charts should be used

Objective: Vaginal birth after caesarean (VBAC) has been suggested to be associated with an increased risk of obstetric anal sphincter injury (compared with primiparous women who birth vaginally). However, prior studies have been small, or used outdated methodology. We set out to validate whether the risk of obstetric anal sphincter injury among women having their first VBAC is greater than that among primiparous women having a vaginal birth. Design: State-wide retrospective cohort study. Setting: Victoria, Australia. Population: All births (455,000) between 2009-2014. Methods: The risk of severe perineal injury between first vaginal birth and first vaginal birth after previous caesarean section was compared, after adjustment for potential confounding variables. Covariates were examined using logistic regression for categorical data and Wilcoxon rank-sum test for continuous data. Missing data were handled using multiple imputation; the analysis was performed using regression adjustment and Stata v16 multiple imputation and teffects suites. Results: Women having a VBAC (n=5,429) were significantly more likely than primiparous women (n=123,353) to sustain a 3rd or 4th degree tear during vaginal birth (7.1 vs 5.7%, p<0.001). After adjustment for mode of birth, body mass index, maternal age, infant birthweight, episiotomy and epidural, there was a 21% increased risk of severe perineal injury (relative risk 1.21 (95%CI 1.07 – 1.38)). Conclusions: Women having their first vaginal birth after caesarean section have a significant increased risk of sustaining a 3rd or 4th degree tear, compared with primiparous women having a vaginal birth. Patient counselling and professional guidelines should reflect this increased risk.

Objective: Identify the proportion of infants reclassified if sex-specific birthweight charts were used, and if this reclassification has an impact on the correlation between birthweight centile and adverse perinatal outcome. Design: Retrospective cohort study Setting: Victoria, Australia. Population: All infants born from 2005-2015 (529,261) Methods: We applied GROW centiles, either adjusted or unadjusted for fetal sex. We compared proportions of small for gestational age (SGA, <10th centile) infants, then the populations of males considered small only by sex-specific charts and females considered small only by unadjusted charts. Main Outcome Measures: Stillbirth, combined perinatal mortality, NICU admissions, Apgars <7 at 5 minutes, emergency caesarean sections. Results: Of those <10th centile by unadjusted charts, 39.6% were male, and 60.5% female. Using sex-specific charts, 50.3% <10th centile were male and 49.7% female. 9,449 (19.2%) females that were SGA according to unadjusted charts were appropriate for gestational age (AGA,>10th-<90th centile) using sex-specific charts. These reclassified newborn females were not at increased risk of adverse outcomes compared with an AGA infant, but were at increased risk of being iatrogenically delivered for suspected growth restriction (RR 4.90, 95%CI 4.39–5.48). 8,048 male infants were reclassified as SGA by sex-specific charts (25% SGA increase). Compared with AGA infants, these reclassified male newborns were at greater risk of stillbirth (RR 1.94, 95%CI 1.30-2.90) and all other adverse perinatal outcomes. Conclusions: Sex-specific growth standards classify a new high-risk cohort of male infants as SGA, and exclude a cohort of females, whose risk is no greater than appropriately grown infants.