Women and Birth 36 (2023) e495–e508

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Women and Birth

journal homepage: www.sciencedirect.com/journal/women-and-birth

A systematic review of behaviour change techniques used in the context of

stillbirth prevention
Tamara Escañuela Sánchez a, b, d, *, Keelin O´Donoghue a, b, Molly Byrne c, Sarah Meaney d,
Karen Matvienko-Sikar e
a
Pregnancy Loss Research Group, Department of Obstetrics and Gynaecology, University College Cork, Cork University Maternity Hospital, Cork, Ireland
b
INFANT Centre, University College Cork, Cork, Ireland
c
Health Behaviour Change Research Group, School of Psychology, NUI Galway, Galway, Ireland
d
National Perinatal Epidemiology Centre (NPEC), University College Cork. Dept. of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
e
School of Public Health, University College Cork, Cork, Ireland

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Stillbirth is one of the most devastating pregnancy outcomes that families can experience. Previous
Stillbirth research has associated a wide range of risk factors with stillbirth, including maternal behaviours such as sub­
Risk factors stance use, sleep position and attendance and engagement with antenatal care. Hence, some preventive efforts
Behaviour change
have been focused on tackling the behavioural risk factors for stillbirth. This study aimed to identify the
Interventions
behavioural risk factors
Behaviour Change Techniques (BCTs) used in behaviour change interventions tacking behavioural risk factors for
Behaviour Change Techniques (BCTs) stillbirth such as substance use, sleep position, unattendance to antenatal care and weight management.
Study design: A systematic review of the literature was conducted in June 2021 and updated in November 2022 in
five databases: CINHAL, Psyhinfo, SociIndex, PubMed and Web of Science. Studies published in high-income
countries describing interventions designed in the context of stillbirth prevention, reporting stillbirth rates
and changes in behaviour were eligible for inclusion. BCTs were identified using the Behaviour Change Tech­
nique Taxonomy v1.
Results: Nine interventions were included in this review identified in 16 different publications. Of these, 4 in­
terventions focused on more than one behaviour (smoking, monitoring fetal movements, sleep position, care-
seeking behaviours), one focused on smoking, three on monitoring fetal movements and one on sleep posi­
tion. Twenty-seven BCTs were identified across all interventions. The most commonly used was “Information
about health consequences” (n = 7/9) followed by “Adding objects to the environment” (n = 6/9). One of the
interventions included in this review has not been assessed for efficacy yet, of the remaining eight, three showed
results in the reduction of stillbirth rates. and four interventions produced behaviour change (smoking re­
ductions, increased knowledge, reduced supine sleeping time).
Conclusions: Our findings suggest that interventions designed to date have limited effects on the rates of stillbirth
and utilise a limited number of BCTs which are mostly focused on information provision. Further research is
necessary to design evidence base behaviour change interventions with a greater focus to tackle all the other
factors influencing behaviour change during pregnancy (e.g.: social influence, environmental barriers).

* Correspondence to: Tamara Escañuela Sánchez, Office 5S30, Cork University Maternity Hospital, Cork, Ireland.
E-mail address: tamara.escanuelasanchez@ucc.ie (T. Escañuela Sánchez).

https://doi.org/10.1016/j.wombi.2023.05.002
Received 10 February 2023; Received in revised form 2 May 2023; Accepted 6 May 2023
Available online 11 May 2023
1871-5192/© 2023 The Authors. Published by Elsevier Ltd on behalf of Australian College of Midwives. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
T. Escañuela Sánchez et al.
Statement of contribution
Problem or issue
• Several risk factors have been associated with an increased risk
of stillbirth, including substance use, attendance at antenatal
care, sleep position and weight related risks.
What is already known on this subject?
• Preventive efforts have been conducted internationally to tackle
this risk factors.
What this paper adds
• The range of BCTs used in the context of stillbirth prevention is
limited and mostly focused on information provision.
• 3 out of 8 interventions reduced the rates of stillbirth, all of the
others succeeded in modifying behaviour.
• Behaviour change interventions with a greater focus are
necessary to tackle the modifiable behavioural risk factors for
stillbirth.
Data Availability
The data that support the findings of this study are available from
the included studies Andrews, Ellwood, Gordon, et al., 2020;
Andrews, Ellwood, Middleton, et al., 2020; Flenady et al., 2019;
Katz et al., 2008; Kember et al., 2018; Lobb et al., 1985; NHS
England, 2019; Saastad et al., 2010, 2011; Subramanian et al.,
2012; Tappin et al., 2015; Tveit et al., 2009; Warland, 2013;
Warland et al., 2018; K. Widdows et al., 2018; Kate Widdows
et al., 2018, 2021) (See Appendix 2). Restrictions apply to the
availability of these data, which were used under license for this
study. Data are available the published articles with the permis­
sion of the journals.
Introduction
Stillbirth is a devastating outcome for expectant parents. Stillbirth
definitions vary across the world, with some countries using different
weight or gestational thresholds, ranging from 350 g to 1000 g and from
20 weeks to 28 weeks [1] which leads to discrepancies when comparing
prevalence rates. However, in 2015, the worldwide estimates for still­
birth at 28 weeks gestations were 3.5 per 1000 total births when looking
at 49 different high-income countries, with the minimum rate being 1.3
in Iceland and the maximum being 8.8 in the Ukraine [2]. Stillbirth rates
have remained steady over many years in high-income countries and
even though most stillbirths in high-income countries occur before la­
bour and are associated with placental pathology [3] some others are
associated with modifiable risk factors [4].
Ota et al. (2020) conducted a systematic review of 43 Cochrane re­
views assessing 61 different stillbirth prevention interventions across
low-, middle and high-income countries [5]. The authors concluded that
few reviews were able to provide clear evidence, as the settings of the
different interventions were too different. Ota et all’s review differs from
the current review in that it focused on a wide range of interventions (i.
e., nutritional interventions, prevention and management of infection,
prevention and management of maternal morbidities, screening, and
management of fetal growth), however, our review is focused on those
interventions conducted in the context of stillbirth prevention with
behavioural focus. Stillbirth has been associated with a wide range of
different risk factors in the literature, and these include behavioural risk
factors. These risk factors include smoking [6–8], drinking alcohol [9,
10], illicit drug use [11–14], lack of attendance or engagement with
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Women and Birth 36 (2023) e495–e508
antenatal care [15,16], sleep position [17] and behaviours associated
with increased maternal weight [18]. Given that these factors have the
potential to be modified, there have been previous efforts to develop and
implement behaviour change interventions to address them and attempt
to reduce the risk of stillbirth.
Being able to identify the different components of the interventions
designed and examined to date in the context of stillbirth prevention is
essential. This kind of work allows to build cumulative evidence that can be
used by intervention designers to plan effective and replicable behaviour
change interventions using systematic methodologies like, for example, the
Behaviour Change Wheel (BCW). The BCW is a systematic methodology to
develop behaviour change interventions, which includes the identification of
relevant BCTs. Identifying the different components of each intervention, or
behaviour change techniques (BCTs) will facilitate this process by providing
detailed information about the different components of the intervention,
especially given the variability across definitions of stillbirth used, outcomes
measured (e.g.: different obstetric outcomes such as aggregated perinatal
death vs. specific definition for stillbirth; different behavioural outcomes such
as reduction in the number of cigarettes smoked, weight loss, number of
baby’s movements, etc.) and the different intervention approaches.
A BCT is an observable, replicable and irreducible component of an
intervention, an "active ingredient", designed to alter or redirect causal
processes that regulate behaviour [19]. Identification of BCTs in in­
terventions allows for accurate replication of interventions and faithful
implementation of interventions demonstrating effectiveness [19].
Taxonomies and ontologies can be used to deconstruct intervention
components. The BCT Taxonomy V.1 (BCTT.V1) is a commonly used
BCT classification and definition system to identify BCTs [20–22]. To
our knowledge, there has not been any systematic review focused on
behaviour change interventions tackling the behavioural risk factors for
stillbirth that were designed to reduce stillbirth rates. Hence, the current
review can be valuable to identify which techniques have been used in
the past to inform the development of future theoretically informed
interventions.
Hence, this systematic review aimed to identify all the Behaviour
Change Techniques (BCTs) that have been used to date in behaviour
change interventions designed to reduce the rates of stillbirth by
addressing modifiable behavioural risk factors such as substance use,
attendance at antenatal care, weight management behaviours or
maternal monitoring of fetal movements.
Methods
This systematic review has been informed by the Preferred Reporting
Items for Systematic Review and Meta-Analysis (PRISMA) guidance for
reporting systematic reviews [23]. The protocol for this review was
submitted to the PROSPERO, Registration code (ID CRD42021264914)
and the protocol has been published [24]; hence, the methods will be
reported in brief here.
Eligibility criteria
Exclusion and inclusion criteria were developed using the PICO
Framework (See Table 1).
Inclusion criteria included (1) interventions with a behavioural focus
that included (2) pregnant women or women up to 12 months post­
partum, that were conducted in (3) high-income countries, and (4) re­
ported changes in rates of stillbirth after the intervention. Case-control
studies, randomised control trials, cross-sectional studies, and quasi-
experimental studies were eligible for inclusion. No limiters were used
in the search.
While we acknowledge that there is an acute need for interventions
in low and middle-income countries, we limited our study to high-
income countries due to the differences between care systems and
challenges associated with improving pregnancy outcomes amongst
low-, middle- and high-income countries. Furthermore, limiting this
T. Escañuela Sánchez et al.
Table 1
PICO Framework.
PICO framework Eligibility criteria
Population or Population: Pregnant women
problem Setting: High-income countries
Intervention or Any intervention designed to prevent stillbirth that includes a
exposure focus on behavioural risk factors.
Comparison Participants who were not exposed to an intervention, who
receive ’standard care’ or who acted as an active comparator
group.
Outcome Behaviour change techniques used in the interventions,
classified using the Behaviour Change Technique Taxonomy
V1[19]
Changes in rates of stillbirth after the intervention, no specific
definition for stillbirth will be used as they differ
internationally.
study to high-income countries might facilitate the use of its findings to
develop behaviour change strategies relevant and applicable to such
contexts.Interventions with a behavioural focus, or behaviour change
interventions, are defined here as those interventions targeting behav­
iours that have been previously associated with an increased risk of
stillbirth including substance use cessation interventions, alternative
packages of antenatal care to increase engagement and weight man­
agement interventions.
Exclusion criteria included interventions that (1) targeted behav­
ioural risk factors for stillbirth but that were not designed to reduce
stillbirth rates or that did not include stillbirth in their measured out­
comes and (2) interventions conducted in middle- or low-income
countries.
Systematic literature search
A systematic search was conducted using CINAHL Complete, SocIn­
dex, Web of Science, PubMed, PsycINFO and Open Grey in September
2021 and updated in November 2022. Keyword searches were used
across four different concepts (1) Stillbirth, (2) Intervention, (3) Preg­
nancy and (4) Study design. The search strategy was developed for
PubMed (See Appendix 1) and was adapted for each relevant database.
Two individual reviewers (TES and KMS) screened titles, abstracts
and full articles using Rayyan against the inclusion and exclusion
criteria to identify relevant articles. A manual check of the reference lists
of included articles was also conducted by TES for review. When the
search identified systematic reviews relevant to the topic, these were
then manually reviewed for potentially relevant articles. Following the
identification of relevant articles, all supplementary materials (e.g.,
intervention leaflets, trial registrations and/or protocols) or other rele­
vant articles associated with the identified interventions were manually
searched to further inform data extraction or quality appraisals.
Data extraction
Study Characteristics
A standardised data extraction sheet was used to extract data by one
reviewer (TES), with extraction reviewed for accuracy by a second
reviewer (KMS).
Data extracted included: (1) General information: Authors, title,
name of intervention/ approach (if applicable), year of publication,
country of origin; (2) Study characteristics: Study aims/objectives, type
of study/report, stillbirth definition used, recruitment strategy; (3)
Participant details: sample size, number of people in the control arm (if
applicable), number of people in the intervention arm (if applicable),
mean age, age range, socio-economic status, education level, ethnicity,
pregnancy status, relationship status; (4) Intervention details: setting,
investigated topic/ target behaviour, description of intervention/
approach and control treatments, delivery mode, intervention duration,
current stage of implementation, outcomes measured in the intervention
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Women and Birth 36 (2023) e495–e508
(e.g. reduction stillbirth rates, increased awareness, behaviour change),
the effectiveness of the intervention.
Quality assessments
Three different quality assessment tools were used depending on the
type of study or report identified in the search. The Cochrane Effective
Practice and Organization of Care (EPOC) risk of bias criteria [25] was
used to assess randomised controlled trials, the Joanna Briggs Institute
Critical Appraisal checklist was used for analytical cross-sectional
studies [26], and the ACCORDS checklist for Grey Literature [27] was
used to assess reports and descriptive studies that were not suitable to be
appraised with the previously stated tools. This approach to quality
appraisal differs from the proposed approach in the study protocol [28]
and represents a comprehensive approach to ensuring that all study
types are evaluated by the most suitable appraisal tool.
To assess the overall quality of the studies, a subjective judgement of
the overall quality of each study was made based on the evaluation of
each item of the relevant tools.
Behaviour change technique coding
Intervention content was coded using the BCTTv1 Taxonomy [19]
and the presence or absence of individual BCTs was recorded in an Excel
sheet. Intervention content was coded using all the relevant documents
for each intervention (e.g., journal articles, protocols, leaflets, reports)
One author (TES) conducted the coding of the BCTs providing evidence
for each one by selecting the fragments of the text supporting the coding
of each BCT. A second author (KMS) reviewed the coded materials and
the identified BCTs. Any discrepancies were discussed until an agree­
ment was reached.
Intervention effects
Intervention effects are presented in table format and summarised in
the body of the text for stillbirth outcomes when reported in the papers.
A meta-analytic approach was not used for intervention effectiveness
given the heterogeneity in the stillbirth definition used and in the
behavioural outcomes measured. Given that the interventions focus on
different behaviours, and that there is only a small number of trials
included in the synthesis, trying to group the interventions into cate­
gories for inclusion in a meta-analysis would not result in robust, reliable
data on intervention effects [29]. This heterogeneity in definitions and
outcomes is also what impedes linking individual BCTs to effectiveness.
Results
Search outcome
The database search identified 8874 studies in September 2021 and
312 studies in November 2022. Of these, 8253 remained after duplicate
removal. After screening titles and abstracts, 38 studies remained
potentially eligible for full-text review. Sixty-six potentially relevant
systematic reviews were also identified when conducting the title
screening, so they were manually reviewed to identify potentially rele­
vant interventions. The result of both screening processes left 55 studies
eligible for full-text screening. From these, 16 articles, representing 9
interventions, met eligibility criteria and were included in the synthesis
(See Fig. 1). From the 16 studies included in the synthesis, additional
study protocols, trial registrations, supplementary materials, reports,
and brochures were identified when available and included in the evi­
dence synthesis. Further, one relevant study relating to one of the
included interventions published in early 2023 was identified after the
last search and was included in the review for additional information. As
such, 31 documents were included in the analysis representing 9
different interventions (Please see Table 2).
T. Escañuela Sánchez et al.
Fig. 1. PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources From: Page MJ, McKenzie JE,
Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi:
10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/.
Study characteristics and quality assessments
Study characteristics are presented in Table 3. For information on the
number of articles and/or additional documents informing Table 3
please refer to Table 2. Studies were published between 1985 and 2023.
Two interventions were conducted in Australia [30,48], 1 in USA [34], 3
in the UK [34,49] and 1 in Norway [42]. One intervention was con­
ducted in Australia and New Zealand [50], another was conducted in
Australia, Canada and USA [46,47]. Of the included studies, 8 were
randomised controlled trials (RCTs) [32,42,46,47,49,50], 2 were
non-randomised control trials [50], 1 was a cross-sectional study [43], 1
was a prospective cohort study [44] and 2 were pre-post intervention
measurements [34,38]. Regarding the behavioural focus of the inter­
vention, 1 intervention was designed to address smoking [33], 3 in­
terventions were designed to focus on monitoring reduced fetal
movements [33,42–45], and 1 intervention was designed to target
women’s sleep position [46,47]. The 4 remaining interventions were
designed to address multiple aspects [30–38], for example, smoking [31,
32,37], tobacco exposure [32], depression [32], intimate partner
violence [32], medical management of growth restriction [31,37],
monitoring of decreased fetal movements [31,34,37], maternal sleep
position [31,34] attendance at antenatal care [34], and timing of birth
[31,37] (See Table 3 for further detail).
Quality appraisals indicated that the overall quality of the included
studies was moderate to good, with some methodological limitations.
The most common issues in RCTs were related to the blinding of par­
ticipants and personnel, and the blinding of outcomes. Cross-sectional
studies had better quality overall, with the most common issues
related to the identification of confounding factors. The two reports [31,
37] assessed with the ACCODS criteria [51] presented no methodolog­
ical limitations (See Appendix 3).
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Behaviour change techniques
A total of 27 BCTs were identified across all 9 interventions. The
most common BCTs were “Adding objects to the environment” (n = 8,
89%) and “Information about health consequences” (n = 7, 78%). The
BCTTv1 Taxonomy [19] contains 3 BCTs related to social support which
when added together were present in 7 out of the 9 interventions (78%)
included in this review, either being “Social support (unspecified)”
(n = 5/9, 55.5%), “Social Support (practical)” (n = 1/9, 1.11%), “Social
support (emotional)” (n = 1/9, 1.11%). The maximum number of BCTs
identified in an intervention was 10 [32], and the minimum was 2 [46].
The mean number of BCTs used in the interventions was 6.11 and the
median was 6 (See Table 4).
The 3 interventions focusing on monitoring fetal movements used 8
different BCTs in total, being "Problem-solving", "Self-monitoring of
behavioural outcomes", "Social Support (unspecified)”, “Instructions on
how to perform the behaviour”, “Information about health conse­
quences”, and “Adding objects to the environment” the most common
BCTs used (present in 3 out of the 3 interventions). The maximum
number of BCTs used in the interventions focusing on monitoring fetal
movements was 6 [44] and the minimum was 3 [45].
Only 1 intervention looking at smoking and another one looking at
sleep position were included in this review. The intervention focusing on
smoking [32] utilised seven different BCTs, and the intervention looking
at sleeping position utilised only two BCTs [46,47] (See Table 4).
The multi-target interventions used a total of 17 different BCTs.
“Instructions on how to perform the behaviour”, “Information about
health consequences” and “Adding objects to the environment were the
most used BCTs in multi-component interventions. The maximum
number of BCTs used was 10 [32], and the minimum number of BCTs
used was 8 [34].
The BCT "Information about health consequences" was
T. Escañuela Sánchez et al.
Table 2
Included interventions and materials.
Author Article title
Intervention 1: The Safer Baby Bundle.
Andrews et al. Implementation and evaluation of a
quality improvement initiative to reduce
late gestation stillbirths in Australia:
Safer Baby Bundle study protocol[30]
Stillbirth in Australia 2: Working
together to reduce stillbirth in Australia:
The Safer Baby Bundle initiative[31]
Intervention 2: An Integrated Randomized Intervention to Reduce Behavioral and Psychosocial Risks
Subramanian An Integrated Randomized Intervention
et al. to Reduce Behavioral and Psychosocial
Risks: Pregnancy and Neonatal Outcomes
[32]
Intervention 3: Keeping baby SAFE
Warland et al. Keeping baby SAFE in pregnancy:
Evaluating the brochure[34]
Intervention 4: Saving Babies’ Lives Care Bundle
Widdows et al. Stillbirth rates, service outcomes and
/ Tommy’s costs of implementing NHS England’s
Saving Babies’Lives care bundle in
maternity units in England: A cohort
study[35]
Evaluation of the implementation of the
Saving Babies ’ Lives Care Bundle in early
adopter NHS Trusts in England[36]
Intervention 5: Financial incentives for smoking cessation
Tappin et al. Financial incentives for smoking
cessation in pregnancy: randomised
controlled trial[39]
Intervention 6: My baby’s movements
Flenady et al. My Baby’s Movements: a stepped wedge
cluster randomised controlled trial to
raise maternal awareness of fetal
movements during pregnancy study
protocol[38]
My Baby’s Movements: a stepped-wedge
cluster-randomised controlled trial of
afetal movement awareness intervention
to reduce stillbirths[40]
My Baby’s Movements: An assessment of
the effectiveness of the My Baby’s
Movements phone program in reducing
late-gestation stillbirth rates[41]
Intervention 7: Count the kicks
Saastad et al. Fetal Movement Counting Improved
Identification of Fetal Growth Restriction controlled trial
and Perinatal Outcomes - a Multi-Centre,
Randomized, Controlled Trial[42]
Saastad et al. Implementation of uniform information
on fetal movement in a Norwegian
population reduced delayed reporting of
decreased fetal movement and stillbirths
in primiparous women - A clinical quality
improvement[43]
Tveit et al. Reduction of late stillbirth with the
introduction of fetal movement
information and guidelines – a clinical
quality improvement[44]
Intervention 8: A controlled study of daily fetal movement counts in the prevention of stillbirths
Women and Birth 36 (2023) e495–e508
Type of studies Additional materials identifieda
Study protocol forLeaflets + website
non-RCT https://stillbirthcre.org.au/about-us/our-work/the-safer-baby-bundle/
Descriptive paper Descriptive paper of development of intervention:
Stillbirth in Australia 2: Working together to reduce stillbirth in Australia: The Safer Baby
Bundle initiative[31]
Safer baby bundle. Handbook and resource guide. https://stillbirthcre.org.
au/wp-content/uploads/2021/03/SBB-Handbook_Final-1.pdf
Leaflet for women https://stillbirthcre.org.
au/wp-content/uploads/2021/03/SB_POSTER_Mums-1.pdf
Leaflets for HCP
https://stillbirthcre.org.au/wp-content/uploads/2021/03/SB_Trifold-DL_HCP-2.pdf
The safer baby bundle video
https://vimeo.com/352404965
Safer baby bundle masterclass
https://stillbirthcre.org.
au/wp-content/uploads/2021/04/SBB_Masterclass_Mainstream_V7_10052022.pdf
Safer Baby Collaborative Summary (Victoria jurisdiction)
https://www.safercare.vic.gov.au/improvement/projects/mbc/safer-baby
Randomised Additional paper describing the design, implementation, challenges faced and acceptability
controlled trial of the intervention: The design, implementation and acceptability of an integrated
intervention to address multiple behavioral and psychosocial risk factors among pregnant
African American women[33].
Additional paper, RCT to assess behaviour change, no pregnancy outcomes reported:
Reducing Psychosocial and Behavioral Pregnancy Risk Factors: Results of a Randomized
Clinical Trial Among High-Risk Pregnant African American Women[34]
Pre-post Brochure
intervention study
Multicentre mixed- Saving Babies’ Lives Version Two Implementation report[37]
methods Protocol: Saving babies’ lives project impact and results evaluation (SPiRE): a mixed
evaluation, pre-post methodology study[38]
intervention study.
Report.
Randomised Trial registration https://clinicaltrials.gov/ct2/show/NCT02606227
controlled trial
Study protocol for Website https://stillbirthcre.org.au/about-us/our-work/my-babys-movement-trial/
RCT
Cluster-RCT
Secondary analysis
of cluster-RCT
Randomised Information leaflet
Trial registration: https://clinicaltrials.gov/ct2/show/NCT00513942
Website: https://countthekicks.org/
Prospective data
collection and
Cross-sectional
study
Prospective cohort
study
(continued on next page)
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T. Escañuela Sánchez et al.
Table 2 (continued )
Author Article title Type of studies
Lobb et al. A controlled study of daily fetal Non-randomised
movement counts in the prevention of trial
stillbirth[45]
Intervention 9: Modifying maternal sleep position in late pregnancy through positional therapy
Warland et al. Modifying Maternal Sleep Position in Randomised
Late Pregnancy Through Positional controlled trial
Therapy: A Feasibility Study[46]
Kember at al. Modifying maternal sleep position in the Randomised
third trimester of pregnancy with controlled trial
positional therapy: a randomised pilot
trial[47]
a
The additional materials identified were used to inform the BCT coding of the interventions and to extract intervention characteristics, but were not submitted to
quality appraisals.
operationalised in different ways depending on the intervention such as
providing information to women who smoked and providing comple­
mentary educational resources. “Adding objects to the environment”
was operationalised as providing videotapes, leaflets, brochures, charts,
or a positioning device (Please see Appendix 3).
Intervention effects
The interventions effects of the interventions included in this review
have been reported narratively in this section. The efficacy findings are
reported as per the original authors.
The interventions focused on maternal monitoring of fetal move­
ments show different results. Intervention number 7 “Reduction of late
stillbirth with the introduction of fetal movement information and
guidelines” [44] reported a reduction in the rates of stillbirth amongst
women presenting with decreased fetal movements from 4.2% to 2.4%
(OR 0.51 95% CI 0.32–0.81, p = 0.004) during the intervention in pri­
miparous women compared to women who presented with decreased
fetal movements in the period before the intervention. Furthermore, the
authors compare their stillbirth rates at baseline and during the inter­
vention period with data from the Medical Birth Registry in Norway, and
conclude that the rates of stillbirth at baseline were comparable, but that
they were significantly lower during the intervention period (OR 0.64;
95% CI 0.47–0.87, p = 0.005). Stillbirth rates among women in the
study cohort were reduced as well from 3.0 per 1000–2.0 per 1000 (OR
0.67; 95% CI 0.48–0.93, p = 0.02); also compared with the general
national stillbirth rate the cohort stillbirth rate was also significantly
lower during the study period (OR 0.64; 95% CI 0.47–0.87, p = 0.005).
This intervention was associated with better detection of fetal growth
restriction as well (from 2.4% to 4.4%, p = 0.020 in term pregnancies (≥
37 weeks) and remained unchanged in the preterm (4.5% vs. 4.0%,
p = 0.604). However, in Intervention number 8 "A controlled study of
daily fetal movement counts in the prevention of stillbirths” [45] the
authors report no changes in pregnancy outcomes or the rates of still­
birth after the intervention. Intervention number 6 “My Baby’s Move­
ments” [40,41,50] did not show statistically significant differences in
stillbirth rates at ≥ 28 weeks of gestation (odds ratio adjusted for cal­
endar time and hospital effects, aOR 1.18, 95% CI 0.93– 1.50; P = 0.18).
Further, when looking specifically at the “My Baby’s Movements” app
users, there were no statistically significant lower rates of stillbirth at
≥ 28 weeks gestation either (aOR 0.79; 95% CI 0.51– 1.23; P = 0.30).
App users had higher rates of induction of labour (aOR 1.10; CI 1.06–
1.14; P < 0.01) and caesarean section, although not statistically signif­
icant in the last case (aOR 1.02; CI 0.98– 1.06; P = 0.33).
One of the included interventions focused on smoking cessation.
Intervention number 5 “Financial incentives for smoking cessation in
pregnancy: randomised controlled trial" [49] reported that more inter­
vention participants stopped smoking compared to the control group
(22.5% vs. 8.5%). However, no differences were observed when looking
at perinatal outcomes such as stillbirth, miscarriage or premature birth.
Women and Birth 36 (2023) e495–e508
Additional materials identifieda
NA
Study protocol followed reported in Warland J, Dorrian J (2014) Accuracy of Self-Reported
Sleep Position in Late Pregnancy. PLoS ONE 9(12): e115760. https://doi.org/10.1371/
journal.pone.0115760
Research protocol obtained from supplementary materials.
Trial registration: https://clinicaltrials.gov/ct2/show/NCT02377817
Regarding the intervention focusing on sleeping position, Interven­
tion number 9 “Modifying Maternal Sleep Position in Late Pregnancy
Through Positional Therapy: A Feasibility Study [46]” concluded that
the use of the PrenaBelt device reduced the time that women spent in the
supine position (3.5% vs. 16.4%, p = 0.03), however, it also reduced the
length of their sleep. No stillbirths occurred in the study sample.
Intervention number 7 “Reduction of late stillbirth with the intro­
duction of fetal movement information and guidelines” [32,33] reported
a decrease in the psychosocial risk factors (smoking, environmental
smoking exposure, depression and intimate partner violence) [52],
however, there were no differences regarding perinatal outcomes
(miscarriage, perinatal death, pre-term and very pre-term birth, low and
very low birth weight, small for gestational age, NICU admission, hos­
pitalisation) [32].
Intervention number 3 “Keeping Baby Safe” [34] reported increases
in the participant’s knowledge regarding stillbirth and risk factors for
stillbirth in the post-intervention measurements.
Intervention number 4, “The Saving Babies’ Lives care bundle”
[34–37] has shown results in the UK. This care bundle has four main
elements: reducing smoking, prevention and surveillance of pregnancies
at risk of growth restriction, raising awareness about reduced fetal
movements, increasing the effectiveness of fetal monitoring during la­
bour and reduction of preterm birth. The authors reported reduced
stillbirth rates in the 20 maternity participating units from 4.2 to 3.4 per
1000 births, which is a greater reduction than the occurred in the rest of
England. However, the authors are not able to attribute this decrease in
stillbirth rates to the implementation of the care bundle, however, as
they report, it is highly plausible that the implementation of the Saving
Babies’ Lives care bundle contributed to this improvement.
Intervention number 1 “The Safer baby bundle” has the objective of
reducing stillbirth by tackling smoking, increasing surveillance of fetal
growth restriction, increasing awareness and monitoring of fetal
movements, awareness of sleep position, and improving decision-
making around the time of birth. The intervention is still in the imple­
mentation phase in most regions of Australia. However, the care bundle
has already been evaluated in the Victoria Jurisdiction, showing a
decrease in the stillbirth rates of 21% (from 0.24–0.19%), and an in­
crease in the number of days without any stillbirths by 131%, from an
average of 3.5 days to 8.1 days. The authors also reported an increase in
smoking cessation rates from an average of 11–33% [53].
Discussion
This is the first review to systematically examine BCTs in behaviour
change interventions that were designed to prevent stillbirth. Nine in­
terventions were identified. Of them, 4 were interventions targeting
multiple behaviours (multi-target interventions), one focused on
smoking, three on monitoring fetal movements, and one on sleep
position.
A total of 27 BCTs were identified across all interventions. Overall,
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Table 3
Intervention Characteristics.
Author, year Aim and target Stillbirth Pregnancy Design Intervention Control Results Tool used for
and country behaviour definition used status of qualitative
participants assessment
and risk of
bias

Intervention 1. The Safer Baby Bundle[30,31]

Andrews et al. To compare Stillbirth at 28 Currently Non- Currently NA. Pre-post Most jurisdictions JBI Checklist
(2020), stillbirth rates at weeks or more recruiting. randomised recruiting. The SBB intervention in Australia are for cross-
Australia. 28 weeks in singleton trial. contains five measures. currently in the sectional
gestation or more pregnancies elements: implementation studies.
across Australian without lethal Element 1: phase. Moderate
maternity settings. fetal congenital Supporting women Victoria quality.
Behavioural abnormalities. to stop smoking in jurisdiction ACCODS.
target: Smoking, pregnancy. showed a decrease High-quality.
monitoring of Element 2: the stillbirth rate
decreased fetal Improving detection by 21%, from an
movements, sleep and management of average rate of
position. fetal growth 0.24–0.19% and
Other elements: restriction an increased the
Timing of delivery Element 3: Raising days between
and education awareness and stillbirths by
about fetal growth improving care for 131%, from an
restriction. women with average of 3.5
decreased fetal days to 8.1 days.
movements
Element 4:
Improving
awareness of
maternal safe going-
to-sleep position in
late pregnancy
Element 5:
Improving decision-
making about the
timing of birth for
women with risk
factors for stillbirth
Intervention 2: Intervention to Reduce Behavioral and Psychosocial Risks[32,33]
Subramanian To address the Perinatal Less than 29 RCT n = 510. Elements n = 515. Usual care Behavioural and Cochrane
et al. impact of an death, no weeks from the successful group. psychosocial risks Effective
(2011), USA intervention on explicit gestation. Smoking Cessation were reduced by Practice and
pregnancy and definition or Reduction in the intervention, Organization
neonatal Pregnancy Program 58.0% of women of Care
outcomes and Treatment (SCRIPT) assigned to the (EPOC) risk of
psychosocial risk trial, the intervention bias criteria.
factors. transtheoretical group resolved Moderate
Behavioural model of behaviour some or all of their quality.
target: Smoking, change, and the risks, whereas
environmental ‘‘pathways to only 48.2% of
tobacco smoke change’’ self-help those receiving
exposure, manual were usual care did so
depression and incorporated. (unadjusted
intimate partner Intervention P = 0.019).
violence sessions were No variation was
provided at each detected on their
routine prenatal impact on
care visit. pregnancy and
neonatal
outcomes.
Intervention 3: Keeping baby SAFE[34]
Warland To determine No explicit Women in Pre-post n = 22. Women NA. Pre-post 85.7% of women JBI Checklist
et al., women’s baseline definition their final intervention were provided with intervention were aware of the for cross-
(2011), knowledge of trimester of study a stillbirth measures. definition and sectional
Australia stillbirth pregnancy information leaflet. prevalence of studies.
incidence and to stillbirth after the Moderate
identify if giving intervention (p- quality.
them an value <0.001), as
information well as improved
brochure about understanding of
stillbirth would risk factors
improve associated with
awareness. stillbirth.
Behavioural No pregnancy
target: Awareness outcomes
about stillbirth reported.
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Table 3 (continued )
Author, year Aim and target Stillbirth Pregnancy Design Intervention Control Results Tool used for
and country behaviour definition used status of qualitative
participants assessment
and risk of
bias

and modifiable
risk factors
including sleep
position,
attendance and
compliance with
antenatal care
appointments,
monitoring baby’s
movements, and
seeking care early.
Intervention 4: Saving Babies’ Lives Care Bundle[35–38]
Widdows The overall The death of a Pre-post Number of NA. Pre-post Stillbirth rates fell JBI Checklist
et al., purpose of the baby before or intervention participants varies intervention in the for cross-
Tommy’s study is to during birth study depending on measures. participating sectional
(2018 – determine the after 24 weeks element of the care maternity units by studies.
2021), UK impact of the care of gestation bundle and NHS 20% from 4.2 to Widdows et al.
bundle on UK expressed as a Trust. Smoking 3.4 per 1000 (2018a). High-
maternity services proportion of monitoring livebirths. This quality.
and perinatal live births cessation: CO rate of reduction Widdows et al.
outcomes. testing for all was greater than (2021). High-
Behavioural pregnant women at seen across the quality.
target: Smoking booking whole of England Widdows et al.
monitoring appointment, over the same (2018b).
cessation, referral of all period. Moderate-
Monitoring fetal women identified as quality.
growth, reduced smokers to smoking
fetal movements cessation services
and effective fetal on an opt out basis /
monitoring in Reduce fetal
labour. Second movements:
version of care information and
bundle also advice leaflet on RM
includes reducing to be provided to all
preterm birth. women by 24 weeks
pregnancy, reduced
fetal movements
discussed at every
antenatal care
appointment, use of
the provided
checklist to manage
care of women who
report RFM.
Intervention 5: Financial incentives for smoking cessation[49]
Tappin et al., To assess Stillbirth is a Mean ECT n = 306. The n = 306. The The number of Cochrane
(2015), UK acceptability and non-registered gestation intervention control group was smokers that Effective
begin to explore outcome. No age at involves offering up offered routine stopped smoking Practice and
efficacy and cost explicit booking to £ 400 of shopping specialist pregnancy was significantly Organization
effectiveness of up definition 12.62 weeks vouchers to support by the stop higher in the of Care
to £ 400 of control participants if they smoking services. incentives group (EPOC) risk of
shopping vouchers group, 12.27 engaged with (22.5% vs. 8.6%). bias criteria.
added to routine weeks services and No differences High-quality.
specialist incentives subsequently quit were seen
pregnancy NHS group smoking. between groups of
“Stop Smoking Intervention neonatal outcome
Services” to help participants or stillbirth rates.
pregnant smokers received £ 50 of
quit. vouchers if they
Behavioural attended their face-
target: Smoking to-face appointment
and set a quit date.
Confirmed quitters
were sent a further
£ 50 voucher.
Twelve weeks after
stopping smoking,
women in the
incentives group
who were quitters
were contacted and,
if confirmed to be
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Table 3 (continued )
Author, year Aim and target Stillbirth Pregnancy Design Intervention Control Results Tool used for
and country behaviour definition used status of qualitative
participants assessment
and risk of
bias

abstinent, were sent

a £ 100 voucher.
Women in the
incentives group
who were confirmed
as abstinent
between 34 and 38
weeks gestation by
the carbon
monoxide breath
test were sent a final
£ 200 voucher.
Intervention 6: My baby’s movements[49]
Flenady et al. To evaluate the Stillbirth at 28 From 28 Cluster RCT. The intervention Control period: The stillbirth rate Cochrane
(2019), effectiveness of a weeks or more weeks consisted of the women will receive was lower during Effective
Australia reduced fetal gestation gestation provision of the “My standard care which the intervention Practice and
and New movements until birth. baby’s movements” includes provision period although Organization
Zealand awareness education package of the bi-national no significantly of Care
Flenady package and including awareness brochure to women (2.2/1000 versus (EPOC) risk of
et al. amobile phone materials for and receiving 2.4/1000 births; bias criteria.
(2022), application for antenatal clinics. information about aOR 1.18, 95% CI Moderate
Australia, women combined Further, it included what constitutes 0.93–1.50; quality.
New with an a mobile phone normal FM and P = 0.18). App
Zealand educational program consisting advice in case of users had higher
program for on a phone app or concerns. rates of induction
clinicians. short message of labour (40.5%
Behavioural service. The app vs 34.3%) (aOR
target: Monitoring sends an alert to 1.10; CI 1.06–
fetal movements prompt woman’s 1.14; P < 0.01).
awareness of her
baby’s movements
at a time and
frequency of her
choice. The app also
provides with a
"movement
counter". The
alternative SMS
program sends a
series of messages to
the woman on a
weekly basis after
28 weeks gestation.
Women are prompt
to seek care if
concerned.
Flenady et al. To evaluate the Stillbirth at 28 Women with Cluster RCT The My Baby’s As above Stillbirth rates
(2023), effectiveness of weeks or more a singleton Movements app were not
Australia, the My Baby’s gestation pregnancy provides statistically lower
New Movements app. without information to raise in app users (1.67/
Zealand major fetal awareness about 1000 vs 2.29/
anomaly at fetal movements 1000) (aOR 0.79;
≥ 28 weeks during pregnancy 95% CI 0.51–
gestation and provides as 1.23; P = 0.30).
were described above.
Intervention 7: Count the kicks[42–44]
Saastad et al., To assess the Perinatal 17–19 weeks RCT n = 544. Women in Control period. No perinatal Cochrane
(2011), effects of death, no gestation the intervention Usual care. deaths occurred in Effective
Norway increased explicit group received an either group. Practice and
awareness definition information However, the Organization
towards fetal brochure, including growth-restricted of Care
activity on instructions on how foetuses were (EPOC) risk of
antenatal to use a fetal more often bias criteria.
identification of movement chart, identified prior to High-quality.
fetal pathology. and were asked to birth in the
Behavioural count fetal intervention
target: Monitoring movements daily group than in the
fetal movements from gestational control group; 20
week 28. The of 23 foetuses
brochure, which (87.0%) versus 12
included a fetal of 20 foetuses
movement chart (a (60.0%),
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Table 3 (continued )
Author, year Aim and target Stillbirth Pregnancy Design Intervention Control Results Tool used for
and country behaviour definition used status of qualitative
participants assessment
and risk of
bias

kick chart), was respectively, [RR:

provided at the 1.5 (95% CI
ultrasound 1.0–2.1)].
Saastad et al. To evaluate an No explicit 17–19 weeks Cross- screening.The The stillbirth rates JBI Checklist
(2010), intervention of definition gestation sectional brochure covered among women for cross-
Norway implementation of study information on: with DFM were sectional
uniform expected normal reduced by almost studies.
information on fetal activity; 50% (OR 0.51; Moderate
fetal activity to differences in 95% CI 0.32–0.81, quality.
women during the perception p = 0.004)) from
antenatal period. according to 4.2% (n = 50) to
Behavioural different fetal 2.4% (n = 73)
target: Monitoring movements, during the
fetal movements maternal position, intervention.
Tveit et al. To examine two Antepartum, All pregnant Prospective the inter- and intra- Stillbirth rate in JBI Checklist
(2009), cohorts of women intrapartum or cohort study individual variation their total cohort for cross-
Norway with DFM before neonatal death between fetuses, of births was sectional
and during a from 28 maternal weight, comparable to the studies. High-
quality completed and smoking; rest of Norway in Quality
improvement weeks of interpretation of the baseline
intervention by gestation variation of fetal observation (OR
implementing activity; 1.06; 95% CI
guidelines for instructions on how 0.70–1.65,
management of to use the kick chart; p = 0.73), and
DFM and uniform and when to contact significantly lower
information on health professionals during the
fetal activity to if experiencing DFM intervention
women. period (OR 0.64;
Behavioural 95% CI 0.47–0.87,
target: Monitoring p = 0.005).
fetal movements.
Intervention 8: A controlled study of
daily fetal movement counts in the prevention of stillbirths[70]
Lobb et al., To assess the Stillbirths were From 28 Non- n = 6597. The n = 13,705. Kick Daily fetal Cochrane
(1985), UK impact of subdivided into weeks randomised Cardiff "Count to chart is introduced movement counts Effective
maternal fetal those weighing gestation trial Ten Kick Chart" was to a selected, high- failed to reduced Practice and
counting on more than introduced by two risk patients and the incidence of Organization
stillbirth 1500 g at birth consultants to all accompanied of intra-uterine of Care
outcomes. and those women booked at usual care. deaths. (EPOC) risk of
Behavioural weighing the Liverpool bias criteria.
target: Monitoring 1500 g or less. Maternity Hospital. Low quality.
fetal movements. The women were
instructed to
telephone the
hospital at 21:00hrs
if they have less
than 10 fetal
movements for 2
days, or no fetal
movements for
12 h.
Intervention 9: Modifying maternal sleep position in late pregnancy through positional therapy[46,47]
Warland To test the Stillbirth or From 32–38 RCT n = 13, Participants n = 13, The study No stillbirths Cochrane
et al., effectiveness of perinatal death weeks are their own lasted for two occurred in the Effective
(2018), PrenaBelt to are not gestation control. Women nights, one night study participants. Practice and
Australia reduce time spent outcomes, were prompted to participants receive The study Organization
and USA sleeping supine in however use a device called the intervention concludes that of Care
a group of healthy ultimate aim of Prenabelt, which whereas the other reducing time (EPOC) risk of
pregnant women device is to causes subtle night participants spent in the supine bias criteria.
in the third reduce the pressure points on are treated as maternal sleep Moderate
trimester of rates of the pregnant user’s control group (no position may ask quality.
pregnancy. stillbirth lower back and device). as a protective
Behavioural buttocks when she factors against
target: Sleep lies in the supine stillbirth.
position. position and
thereby activate her
body’s natural
mechanisms to
spontaneously
reposition to
maintain comfort
and reduce time
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Table 3 (continued )
Author, year Aim and target Stillbirth Pregnancy Design Intervention Control Results Tool used for
and country behaviour definition used status of qualitative
participants assessment
and risk of
bias

spent sleeping
supine.
Kember et al. To evaluate Stillbirth or Between 28 Randomised n = 10. Each n = 10. Each The percentage of Cochrane
2018 whether the perinatal death and 37 pilot trial participant participant sleep time supine Effective
(Canada, percentage of time are not weeks underwent two underwent two on the PrenaBelt Practice and
USA, spent supine outcomes, gestation overnight overnight night (n = 20) and Organization
Ghana) during sleep in the however polysomnograms, polysomnograms, sham night of Care
third trimester of ultimate aim of one wearing the one wearing the (n = 20) was 3.5% (EPOC) risk of
pregnancy could device is to Prenabelt device Prenabelt device (0–16.6) and bias criteria.
be reduced using a reduce the and another one and another one 16.4% (3.5–25.3), High-quality.
positional therapy rates of wearing a sham. The wearing a sham. respectively.
device (PrenaBelt) stillbirth PrenaBelt is worn at The sham was Use of the
compared with a the level of the waist identical to the PrenaBelt resulted
sham device. and has four firm PrenaBelt but had in a reduction in
Behavioural plastic balls soft foam balls the percentage of
target: Sleep embedded into foam instead of firm sleep time supine
position. inserts within the plastic balls. It did in comparison
pockets posteriorly. not provide pressure with the sham,
When women are points.
supine, the balls
apply pressure
points across the
woman’s lower
back, prompting her
to change position
to a lateral position
to remain
comfortable.

the number of BCTs used in the nine interventions was small, accounting
for 29% of the total BCTs available in the BCT(v1) Taxonomy. The BCT
that was most used across all interventions were "Information about
health consequences" and "Adding objects to the environment" which
usually were additional informative materials, followed by the BCTs
associated with social support combined. All of these BCTs have the
potential to produce behaviour change by improving women’s psycho­
logical capabilities and social opportunities. This is understandable
given pregnant women’s desire for education and concerns on how to
improve or maintain their health status during their pregnancy [54].
However, we know from previous research that the information pro­
vided in general antenatal care regarding health habits and risk factors
for stillbirth is very scarce, or non-existent [55].
We have not been able to link the different BCTs to intervention ef­
fects due to the heterogeneity of the interventions. Our results show
that, by looking at the individual findings of each intervention, two
interventions “Safer Baby Bundle” and the “Saving Babies Lives” care
bundle, which both have a multi-component approach, might have had a
positive influence in reducing stillbirth rates. This is in concordance
with previously developed behaviour change interventions targeting
different outcomes, where authors have concluded that multi-layered
interventions targeting individual, societal and environmental-level
determinants are more effective [56–58].
Behaviour change during pregnancy is influenced by several
different factors including psychological and cognitive factors, social
factors, structure/service level factors, social factors and environmental
factors [59–61]. Alcántara et al. (2020) conducted a systematic review
of behaviour change interventions to determine which types of social
determinants were tested as moderators of behaviour change in­
terventions. The authors concluded that, even though almost half of the
interventions tested social determinants of health moderators, most
studies were atheoretical, lacked diversity, were methodologically poor,
and were too focused on the individual level [62]. The fact that
multi-component interventions tackle different social determinants or
behaviours at once might be the reason why they have had success
tackling the risk factors for stillbirth or producing behaviour change.
These types of interventions are also the ones that were composed of the
biggest number of different BCTs. However, as Alcántara et al. discussed
in their review, there is an increased need to design better theoretically
informed and diverse behaviour change interventions to determine
which social determinants of health moderators are effective in health
behaviour change interventions and which BCTs are the most appro­
priate to tackle them [62].
Our review findings show that most of the interventions have a
strong focus on providing information either by directly communicating
with women or by providing women with additional materials such as
books, leaflets, websites or videos. Providing women with information
on the importance of engaging in certain behaviours and disengaging
from others is very relevant and might act as a first step towards
behaviour change [63] but it also involves some challenges. Previous
research has demonstrated that women might show different attitudes
towards receiving information about stillbirth or behavioural risk fac­
tors for stillbirths, and whereas some women would receive this infor­
mation positively and understand it as a tool to support prevention
efforts, for others it might cause anxiety [55]. Hence, the importance of
language and communication style is essential. Communicating about
stillbirth also poses some challenges for healthcare professionals. Pre­
vious research has shown that talking about sensitive issues such as
weight management or substance use can be uncomfortable or stressful
for healthcare professionals [64–66]. Intervention designers need to
consider these complications when assessing the feasibility and
acceptability of their interventions. Further, it is possible that adding
concrete elements such as action or goal planning, instructions on how
to perform the behaviour, or practical social support contributes to
addressing the potential uncertainties that the information provided
might arise.
We know from previous research that lack of social support can act as
a barrier to behaviour change during pregnancy [59,67,68]. Social
contexts and norms are important and some women may have few
positive role models in their social milieu, adding pressure on women to

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Table 4
BCTs identified in the interventions.
Behavioural target of Multi-target interventions Smoking Maternal monitoring of fetal movements Sleep
intervention position
Intervention 1. The 2. Intervention to 3. Keeping 4. Saving 5. Financial 6. My Baby’s 7. Introduction of 8. A controlled 9. Modifying
safer Reduce baby SAFE babies’ incentives for Movements fetal movement study of daily Maternal
baby Behavioural and in lives smoking information and fetal Sleep
bundle Psychosocial pregnancy project cessation guidelines movement Position
Risks counts

1.1. Goal setting x x

(behaviour)
1.2 Problem solving x
1.4. Action planning x x x x
2.1. Monitoring of x x
behaviour
2.2 Feedback on x
behaviour
2.3. Self-monitoring x x
of behaviour
2.4. Self-monitoring x x
of outcomes of
behaviour
2.5. Monitoring of x
outcome(s) of
behaviour without
feedback
2.6. Biofeedback x
3.1. Social support x x x x x
(unspecified)
3.2 Social support x
(practical)
3.3. Social support x
(emotional)
4.1. Instruction on x x x x x
how to perform the
behaviour
5.1. Information x x x x x x x
about health
consequences
5.2. Salience of x
consequences
6.2. Social x
comparison
7.1. Prompts cues x x
7.5. Remove aversive x
stimulus
10.1. Material x
incentive
(behaviour)
10.2. Material reward x
(behaviour)
10.4. Social reward x
10.5. Social incentive
10.10. Reward x
(outcome)
11.1. x x
Pharmacological
support
12.2. Restructuring x
the social
environment
12.5. Adding objects x x x x x x x x
to the environment
16.3. Vicarious x
consequences

avoid social exclusion, or providing inaccurate information [59,67].
Further, the lack of social support to help women share their daily re­
sponsibilities (e.g, with other children) can also act as a barrier to
engaging in healthy behaviours [59,67]. However, social support can
also act as a facilitator of behaviour change when it is present. Having
supportive partners that do not engage in unhealthy behaviours them­
selves or encourage family and friends has been reported as facilitators
[59,67,68], as well as access to empathetic and understanding health­
care professionals [59,67]. This might explain the high level of social
support BCTs (either practical, emotional, or unspecified) in the
interventions included in this review. These BCTs are present in seven of
the nine interventions included in this review; however, their oper­
ationalisation is in general quite vague. Hence, further research is
necessary to determine how to establish consistent social support that
facilitates engagement with behaviour-change interventions during
pregnancy.
Strengths and limitations
Firstly, this is the first review to systematically examine behaviour

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change interventions to reduce the risk of stillbirth and to identify the
BCTs included in such interventions. There are several reviews pub­
lished in the literature examining behaviour change interventions tar­
geting risk factors for stillbirth (such as smoking or high BMI), and also
reviews examining all available interventions to reduce the risk of
stillbirth. However, we ensured this review only included interventions
that were designed with the explicit purpose of reducing stillbirth and
that included only behaviour change interventions, as opposed to, for
example, interventions affecting care management. The use of the BCT
Taxonomy V1 [19] for the identification and coding of BCTs is a strength
of this review. Coding the interventions using the BCTTv1 Taxonomy
[19] provides a more detailed examination of the different components
of an intervention, which might result in the identification of potentially
effective components [20]. However, there is a need for further research
to develop an approach that facilitates linking BCTs to effectiveness
across heterogeneous interventions and outcomes.
To date, establishing the link between individual BCTs and inter­
vention effectiveness is not possible given the heterogeneity of the
different interventions tackling stillbirth. However, some approaches
are being currently developed to tackle this issue. Johnson et al., (2022)
proposed in their protocol a method to provide preliminary information
about the effectiveness of commonly used intervention components
(used in five or more interventions) in their review of early childhood
obesity prevention interventions [22]. Although the authors acknowl­
edge that their approach will not be able to determine the independent
effects of each component, it might be a step closer to linking individual
BCTs to intervention effectiveness, which would inform intervention
design as to which "active ingredients" are necessary for a behaviour
change intervention to be effective. Taxonomies and ontologies can be
used to deconstruct intervention components. These new approaches
might facilitate linking individual BCTs to intervention effectiveness.
Further research in this regard is also necessary to develop methodolo­
gies that allow intervention designers to determine the independent
effects of each component over an outcome of interest. However, iden­
tifying which BCTs have been used to date in successful interventions is
important to inform the development of new interventions.
We have focused our analysis on the behavioural aspects of the in­
terventions included. However, it is important to highlight that some
interventions such as the Saving Babies’ Lives Care Bundle [35–38],
which has reported reductions in stillbirth rates, also included elements
associated with the behaviour of and care provided by healthcare pro­
fessionals. This highlights the fact that strong support by the institutions
and professionals providing care is possibly necessary to reduce the rates
of stillbirth.
Conclusion
Our findings show that multi-target interventions (interventions
targeting multiple behaviours) seem to have the best potential for suc­
cess. Further research on the factors affecting behaviour change during
pregnancy needs to be conducted to design evidence-based behaviour
change interventions that go beyond information provision and that
include more concrete action to produce behaviour change, utilising
BCTs such as “Instructions on how to perform a behaviour”, “Goal set­
tings” and “Action Planning”. Using structured methodologies like the
Behaviour Change Wheel [69] for intervention design can help to
identify and address all the factors influencing behaviour change by
selecting appropriate intervention functions, and guides to select useful
BCTs as well as potential operationalisation of BCTs [69].
Finally, further research is essential to establish the efficacy of the
different BCTs to inform the development of future stillbirth prevention
interventions.
Systematic review registration
The protocol for this review was submitted to PROSPERO,
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Women and Birth 36 (2023) e495–e508
Registration code (ID CRD42021264914). Published protocol https://
hrbopenresearch.org/articles/4–92.
Data Availability
The data that support the findings of this study are available from the
included studies Andrews, Ellwood, Gordon, et al., 2020; Andrews,
Ellwood, Middleton, et al., 2020; Flenady et al., 2019; Katz et al., 2008;
Kember et al., 2018; Lobb et al., 1985; NHS England, 2019; Saastad
et al., 2010, 2011; Subramanian et al., 2012; Tappin et al., 2015; Tveit
et al., 2009; Warland, 2013; Warland et al., 2018; K. Widdows et al.,
2018; Kate Widdows et al., 2018, 2021) (See Appendix 2). Restrictions
apply to the availability of these data, which were used under license for
this study. Data are available the published articles with the permission
of the journals.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the
online version at doi:10.1016/j.wombi.2023.05.002.
References
[1] K. Kelly, S. Meaney, S. Leitao, K. O’Donoghue, A review of stillbirth definitions: a
rationale for change, Eur. J. Obstet. Gynecol. Reprod. Biol. 256 (2021) 235–245.
[2] V. Flenady, et al., Stillbirths: recall to action in high-income countries, Lancet
(Lond., Engl. ) 387 (2016) 691–702.
[3] J.E. Lawn, et al., Stillbirths: rates, risk factors, and acceleration towards 2030,
Lancet 387 (2016) 587–603.
[4] V. Flenady, et al., Stillbirths: recall to action in high-income countries, Lancet 387
(2016) 691–702.
[5] E. Ota, et al., Antenatal interventions for preventing stillbirth, fetal loss and
perinatal death: an overview of Cochrane systematic reviews, Cochrane Database
Syst. Rev. 12 (2020) CD009599.
[6] M.W. Varner, et al., Association between stillbirth and illicit drug use and smoking
during pregnancy, Obs. Gynecol. 123 (2014) 113–125.
[7] T.C. Marufu, A. Ahankari, T. Coleman, S. Lewis, Maternal smoking and the risk of
still birth: systematic review and meta-analysis, BMC Public Health 15 (2015).
[8] V. Flenady, et al., Stillbirths: the way forward in high-income countries, Lancet 377
(2011) 1703–1717.
[9] M.H. Aliyu, et al., Alcohol consumption during pregnancy and the risk of early
stillbirth among singletons, Alcohol 42 (2008) 369–374.
[10] A.-M.N. Andersen, P.K. Andersen, J. Olsen, M. Grønbaek, K. Strandberg-Larsen,
Moderate alcohol intake during pregnancy and risk of fetal death, Int. J. Epidemiol.
41 (2012) 405–413.
[11] V. Flenady, et al., Major risk factors for stillbirth in high-income countries: a
systematic review and meta-analysis, Lancet 377 (2011) 1331–1340.
[12] T. Escañuela Sánchez, S. Meaney, K. O’Donoghue, Modifiable risk factors for
stillbirth: a literature review, Midwifery 79 (2019).
[13] J. Platts, et al., The Midland and North of England Stillbirth Study (MiNESS), BMC
Pregnancy Childbirth 14 (2014).
[14] A.E.P. Heazell, et al., Association between maternal sleep practices and late
stillbirth – findings from a stillbirth case-control study, BJOG Int. J. Obstet.
Gynaecol. 125 (2018) 254–262.
[15] B. Reime, et al., Does underutilization of prenatal care explain the excess risk for
stillbirth among women with migration background in Germany? Acta Obstet.
Gynecol. Scand. 88 (2009) 1276–1283.
[16] T. Stacey, et al., Antenatal care, identification of suboptimal fetal growth and risk
of late stillbirth: Findings from the Auckland Stillbirth Study, Aust. N. Zeal. J.
Obstet. Gynaecol. 52 (2012) 242–247.
[17] T. Stacey, et al., Association between maternal sleep practices and risk of late
stillbirth: a case-control study, BMJ 342 (2011) d3403.
[18] L.M. Bodnar, et al., Maternal prepregnancy obesity and cause-specific stillbirth,
Am. J. Clin. Nutr. 102 (2015) 858–864.
[19] S. Michie, et al., The behavior change technique taxonomy (v1) of 93 hierarchically
clustered techniques: building an international consensus for the reporting of
behavior change interventions, Ann. Behav. Med. 46 (2013) 81–95.
[20] J. Presseau, et al., Using a behaviour change techniques taxonomy to identify
active ingredients within trials of implementation interventions for diabetes care,
Implement. Sci. 10 (2015) 1–10.
[21] C.E. Wood, et al., Reporting behaviour change interventions: do the behaviour
change technique taxonomy v1, and training in its use, improve the quality of
intervention descriptions? Implement. Sci. 11 (2016) 1–11.
[22] B.J. Johnson, et al., Unpacking the behavioural components and delivery features
of early childhood obesity prevention interventions in the TOPCHILD
Collaboration: a systematic review and intervention coding protocol, BMJ Open 12
(2022).
[23] M.J. Page, et al., The PRISMA 2020 statement: an updated guideline for reporting
systematic reviews, BMJ vol. 372 (2021).
T. Escañuela Sánchez et al.
[24] T. Escañuela Sánchez, et al., A protocol for a systematic review of behaviour
change techniques used in the context of stillbirth prevention [version 2; peer
review: 1 approved, 1 approved with reservations], HRB Open Res. 4 (2022) 92.
[25] Cochrane library, Effective practice and organisation of care. Suggested risk of bias
criteria for EPOC reviews 1, Risk bias Stud. a Sep. Control Group (2017) 1–4.
[26] S. Moola, et al., Checklist for analytical cross sectional studies, Joanna Briggs Inst.
Rev. Man. (2017) 1–7.
[27] J. Tyndall, AACODS checklist, Chin. J. Evid. -Based Med 7 (2010) 507–513.
[28] Escañuela Sánchez, T., Byrne, M., Meaney, S., Donoghue, K.O. & Matvienko-sikar,
K. A protocol for a systematic review of behaviour change techniques used in the
context of stillbirth prevention [version 1; peer review: 1 approved with
reservations]. 1–9 (2021).
[29] K. Matvienko-Sikar, et al., Behaviour change techniques and theory use in
healthcare professional-delivered infant feeding interventions to prevent childhood
obesity: a systematic review, Health Psychol. Rev. 13 (2019) 277–294.
[30] C.J. Andrews, et al., Implementation and evaluation of a quality improvement
initiative to reduce late gestation stillbirths in Australia: safer Baby Bundle study
protocol, BMC Pregnancy Childbirth 20 (2020) 694.
[31] C.J. Andrews, et al., Stillbirth in Australia 2: working together to reduce stillbirth
in Australia: the Safer Baby Bundle initiative, Women Birth 33 (2020) 514–519.
[32] S. Subramanian, et al., An integrated randomized intervention to reduce behavioral
and psychosocial risks: pregnancy and neonatal outcomes, Matern. Child Health J.
16 (2012) 545–554.
[33] K.S. Katz, et al., The design, implementation and acceptability of an integrated
intervention to address multiple behavioral and psychosocial risk factors among
pregnant African American women, BMC Pregnancy Childbirth 8 (2008) 1–22.
[34] J. Warland, Keeping baby SAFE in pregnancy: evaluating the brochure, Midwifery
29 (2013) 174–179.
[35] K. Widdows, S.A. Roberts, E.M. Camacho, A.E.P. Heazell, Stillbirth rates, service
outcomes and costs of implementing NHS England’s saving Babies’ lives care
bundle in maternity units in England: a cohort study, PLoS One 16 (2021) 1–16.
[36] Widdows, K., Roberts, S., Camacho, E. & Heazell, A.E.P. Evaluation of the
implementation of the Saving Babies ’ Lives Care Bundle in early adopter NHS Trusts in
England. (2018).
[37] N.H.S. England. Saving Babies’ Lives Version Two. 〈https://www.england.nhs.
uk/mat-transformation/saving-babies/〉 (2019).
[38] K. Widdows, H.E. Reid, S.A. Roberts, E.M. Camacho, A.E.P. Heazell, Saving babies’
lives project impact and results evaluation (SPiRE): A mixed methodology study,
BMC Pregnancy Childbirth 18, 1-N. PAG (2018).
[39] D. Tappin, et al., Financial incentives for smoking cessation in pregnancy:
randomised controlled trial, BMJ 350 (2015) 1–12.
[40] V. Flenady, et al., My Baby’s Movements: a stepped-wedge cluster-randomised
controlled trial of a fetal movement awareness intervention to reduce stillbirths,
BJOG Int. J. Obstet. Gynaecol. 129 (2022) 29–41.
[41] S. Skalecki, et al., My Baby’s Movements: an assessment of the effectiveness of the
My Baby’s Movements phone program in reducing late-gestation stillbirth rates,
Aust. N. Zeal. J. Obstet. Gynaecol. (2023) 1–6, https://doi.org/10.1111/ajo.13647.
[42] E. Saastad, B.A. Winje, B.S. Pedersen, J.F. Frøen, Fetal movement counting
improved identification of fetal growth restriction and perinatal outcomes - a
multi-centre, randomized, controlled trial, PLoS One 6 (2011) 1–10.
[43] E. Saastad, et al., Implementation of uniform information on fetal movement in a
Norwegian population reduced delayed reporting of decreased fetal movement and
stillbirths in primiparous women - a clinical quality improvement, BMC Res. Notes
3 (2010).
[44] J. Tveit et al. Reduction of late stillbirth with the introduction of fetal movement
information and guidelines-a clinical quality improvement. (2009) doi:10.1186/
1471–2393-9–32.
[45] M.O. Lobb, J.M. Beazley, N.G. Haddad, A controlled study of daily fetal movement
counts in the prevention of stillbirths, J. Obstet. Gynaecol. (Lahore). 6 (1985)
87–91.
[46] J. Warland, et al., Modifying maternal sleep position in late pregnancy through
positional therapy: a feasibility study, J. Clin. Sleep. Med. 14 (2018) 1387–1397.
[47] A.J. Kember, et al., Modifying maternal sleep position in the third trimester of
pregnancy with positional therapy: a randomised pilot trial, BMJ Open 8 (2018).
e508
Women and Birth 36 (2023) e495–e508
[48] J. O’Leary, J. Warland, Untold stories of infant loss: the importance of contact with
the baby for bereaved parents, J. Fam. Nurs. 19 (2013) 324–347.
[49] D. Tappin, et al., Financial incentives for smoking cessation in pregnancy:
Randomized controlled trial, Obstet. Gynecol. Surv. 70 (2015) 297–298.
[50] V. Flenady, et al., My Baby’s Movements: a stepped wedge cluster randomised
controlled trial to raise maternal awareness of fetal movements during pregnancy
study protocol, BMC Pregnancy Childbirth 19 (2019) 430.
[51] Appraisal (The AACODS Checklist) - Grey Literature in Health, Flinders Univ.
(2010). 〈https://canberra.libguides.com/c.php?g=599348&p=4148869〉.
[52] J.G. Joseph, et al., Reducing psychosocial and behavioral pregnancy risk factors:
results of a randomized clinical trial among high-risk pregnant African American
women, Am. J. Public Health 99 (2009) 1053–1061.
[53] Safer baby collaborative | Safer Care Victoria, Safer Baby Vic. (2022).
〈https://www.safercare.vic.gov.au/improvement/projects/mbc/safer-baby〉.
[54] M.M.A. Almalik, S.M. Mosleh, Pregnant women: what do they need to know during
pregnancy? A descriptive study, Women Birth 30 (2017) 100–106.
[55] T. Escañuela Sánchez, K. Matvienko-Sikar, S. Meaney, K. O’Donoghue, Exploring
first time mothers’ experiences and knowledge about behavioural risk factors for
stillbirth, Heal. Expect. (2022) 1–14, https://doi.org/10.1111/hex.13662.
[56] N.T. Hadgraft, et al., Reducing occupational sitting: workers’ perspectives on
participation in a multi-component intervention, Int. J. Behav. Nutr. Phys. Act. 14
(2017) 1–13.
[57] B. Spring, et al., Multicomponent mHealth intervention for large, sustained change
in multiple diet and activity risk behaviors: the make better choices 2 randomized
controlled trial, J. Med. Internet Res. 20 (2018) 1–13.
[58] L. Matwiejczyk, K. Mehta, J. Scott, E. Tonkin, J. Coveney, Characteristics of
effective interventions promoting healthy eating for pre-schoolers in childcare
settings: an umbrella review, Nutrients 10 (2018).
[59] T. Escañuela Sánchez, et al., Facilitators and barriers influencing weight
management behaviours during pregnancy: a meta-synthesis of qualitative
research, BMC Pregnancy Childbirth 22 (2022) 1–21.
[60] T. Escañuela Sánchez, et al., Facilitators and barriers to substance-free pregnancies
in high-income countries: A meta-synthesis of qualitative research, Women Birth
35 (2021) e99–e110.
[61] T. Escañuela Sánchez, L. Linehan, K. O’Donoghue, M. Byrne, S. Meaney,
Facilitators and barriers for seeking and engaging in antenatal care in high-income
countries: a meta-synthesis of qualitative research. Poster abstracts of the ISPD
25th International Conference on Prenatal Diagnosis and Therapy, Virtual, 6–8
June 2021, Prenat. Diagn. 41 (2021) 10–153.
[62] C. Alcántara, et al., Social determinants as moderators of the effectiveness of health
behavior change interventions: scientific gaps and opportunities, Health Psychol.
Rev. 14 (2020) 132–144.
[63] K.R. Arlinghaus, C.A. Johnston, Advocating for behavior change with education,
Am. J. Lifestyle Med. 12 (2018) 113–116.
[64] R. Dieterich, J. Demirci, Communication practices of healthcare professionals
when caring for overweight/obese pregnant women: a scoping review, Patient
Educ. Couns. 103 (2020) 1902–1912.
[65] L.C. van Boekel, E.P.M. Brouwers, J. van Weeghel, H.F.L. Garretsen, Stigma among
health professionals towards patients with substance use disorders and its
consequences for healthcare delivery: systematic review, Drug Alcohol Depend.
131 (2013) 23–35.
[66] K.M. Renbarger, C. Shieh, M. Moorman, K. Latham-Mintus, C. Draucker, Health
care encounters of pregnant and postpartum women with substance use disorders,
West. J. Nurs. Res. 42 (2019) 612–628.
[67] T. Escañuela Sánchez, L. Linehan, K. O’Donoghue, M. Byrne, S. Meaney,
Facilitators and barriers to seeking and engaging with antenatal care in high-
income countries: a meta-synthesis of qualitative research, Health Soc. Care
Community 00 (2022) 1–19.
[68] L. Rockliffe, S. Peters, A.E.P. Heazell, D.M. Smith, Understanding pregnancy as a
teachable moment for behaviour change: a comparison of the COM-B and
teachable moments models, Heal. Psychol. Behav. Med. 10 (2022) 41–59.
[69] S. Michie, L. Atkins, R. West, The Behaviour Change Wheel: A Guide to Designing
Interventions, Silverback Publishing, 2014.
[70] When it kicks in the womb – what does this mean?.