Respectful language in intrapartum and newborn care – Authors' reply
Authors: Dilys Walker, Phelgona Otieno, Peter Waiswa
Journal: The Lancet Global Health (2020)

We thank Claudia Ravaldi and colleagues for raising the important point about the use of language in our paper1Walker D Otieno P Butrick E et al.Effect of a quality improvement package for intrapartum and immediate newborn care on fresh stillbirth and neonatal mortality among preterm and low-birthweight babies in Kenya and Uganda: a cluster-randomised facility-based trial.Lancet Glob Health. 2020; 8: e1061-e1070Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar describing the results of our intrapartum and newborn care quality improvement package, and regret any harm caused by our choice to use the term fresh stillbirth. We appreciate being called to task on the insensitivity of the use of this terminology, and recognise that language matters. When we embarked on our trial, which aimed to improve outcomes for preterm babies aged up to 28 days, through a package of improved care around the time of birth, we committed to using local data systems. Our intervention package aimed to improve quality of care through the promotion of evidence-based practices in a synergistic package of interventions that included data strengthening, use of a modified version of the WHO Safe Childbirth Checklist adapted for preterm birth, quality improvement collaboratives, and provider training and mentoring through PRONTO, an approach grounded in highly realistic simulation and team training. Our aim was to improve outcomes at age 28 days; averting stillbirths was an important pathway to success. We agree with Ravaldi and colleagues that intrapartum stillbirth was an appropriate target, and we designed the intervention with this in mind. However, in our commitment to use existing facility data sources—in particular, maternity registers—we felt bound to the existing indicator terms and definitions used by the health system, including the designation of stillbirths as fresh or macerated. In settings that often do not have consistent fetal monitoring, accurately identifing intrapartum stillbirth, defined as fetal death that occurred after the onset of labour and before birth, is almost impossible. Given the documented inaccuracies in low-income and middle-income countries to record the time of death before or after facility admission,2Gold KJ Abdul-Mumin AR Boggs ME Opare-Addo HS LR Assessment of “fresh” versus “macerated” as accurate markers of time since intrauterine fetal demise in low-income countries.Int J Gynaecol Obs. 2014; 125: 223-227Crossref PubMed Scopus (45) Google Scholar we chose to report our results as reflected in the original source documents, rather than interpret their meaning. As of 2015, shortly before our study began, the WHO Global Reference List of 100 Core Health Indicators3WHOWHO Global Reference List of 100 Core Health Indicators. World Health Organization, Geneva2015Google Scholar recognises the additional dimension and disaggregation of fresh and macerated stillbirth for the stillbirth indicator. The term fresh stillbirth is still widely used in the settings in which we were working, and is likely to be more widely understood in this context than intrapartum stillbirth. Further, although we would have liked more precision around the timing of fetal death, the quality of the data for this outcome is a challenge in low-resource settings and has been well documented in the literature.4Flenady V Wojcieszek AM Ellwood D et al.Classification of causes and associated conditions for stillbirths and neonatal deaths.Semin Fetal Neonatal Med. 2017; 22: 176-185Summary Full Text Full Text PDF PubMed Scopus (31) Google Scholar Nonetheless, in reflecting on the language we used in our project, there was a potential missed opportunity to more deeply engage the providers in dialogue about respectful, person-centred use of language in care practices and documentation in facility records. We agree that a more respectful phrase could be used, although we find intrapartum stillbirth to be too technical. We appreciate these concerns being brought to our attention and the opportunity to be part of this important global conversation as we bring the tragedy of stillbirths to light. We hope in the future that we will succeed in more fully supporting the tenets of respectful care in our use of language in publications and more broadly. DW is cofounder of PRONTO International. All other authors declare no competing interests. Effect of a quality improvement package for intrapartum and immediate newborn care on fresh stillbirth and neonatal mortality among preterm and low-birthweight babies in Kenya and Uganda: a cluster-randomised facility-based trialFresh stillbirth and neonatal mortality among low-birthweight and preterm babies can be decreased using a package of interventions that reinforces evidence-based practices and invests in health system strengthening. Full-Text PDF Open AccessRespectful language in intrapartum and newborn careDilys Walker and colleagues (August, 2020)1 describe the efficacy of a quality improvement package for intrapartum and immediate newborn care. It was encouraging to see that such a package reduced the risk of intrapartum stillbirth and neonatal mortality among preterm and low-birthweight babies in Kenya and Uganda, saving hundreds of babies’ lives. Full-Text PDF Open Access