Stillbirths – a hidden loss
Barriers to recording and reducing stillbirths
Lack of clarity and consistency in definitions
Fetal death: The International Classification of Diseases, Revision 10 (ICD-10) defines a fetal death as "death prior to the complete expulsion or extraction from its mother of a product of conception, irrespective of the duration of pregnancy; the death is indicated by the fact that after such separation the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles" without specification of the duration of pregnancy. |
Early fetal deaths: According to the ICD-10, an early fetal death is death to a fetus weighing at least 500 grams (or, if birth weight is unavailable, after 22 completed weeks gestation, or with a crown-heel length of 25 centimetres or more) [57]. |
(Birth weight is prioritised over gestational age because when ICD 10 was developed in the 1980s birth weight was believed to be more reliably reported. However globally less than half of live births are weighed and very few stillbirths are weighed, and gestational age data is more available at least based on Last Menstrual Period.) |
Late fetal deaths (stillbirths): A late fetal death is defined as a fetal death weighing at least 1000 grams (or a gestational age of 28 completed weeks or a crown-heel length of 35 centimetres or more) [57]. The ICD-10 recommends this definition for the purposes of international comparison. |
Stillbirths: Stillbirth is the colloquial term commonly used term for fetal death, and is the term used in this series to refer to both early and late fetal deaths. |
Stillbirth rate: As the data used here is for international comparison, all stillbirth rate data refer to late fetal deaths i.e. the number of babies born dead after 28 weeks of gestation per 1,000 total births. |
Early neonatal mortality rate: The number of early neonatal deaths (deaths in the first 7 days of life) per 1,000 live births. |
Perinatal period: This time interval includes some portion of late pregnancy and some or all of the first month of life. It has been used to refer to at least 10 different time periods depending on the time period cut offs used. The term "perinatal" is also used to refer to some, but not all causes of neonatal death in the ICD-10 [57]. Hence the term often causes confusion [14]. In this paper, we use perinatal deaths to include stillbirths after 28 weeks gestational age and early neonatal deaths in the first 7 days of life. In general, however, we have specified the outcome (stillbirth, or neonatal) or the cause of death where the data has allowed this distinction. |
Limited and poor quality data on stillbirth rates and numbers
Lack of systematic estimates for causes of stillbirths
Poor understanding of mechanisms and risk factors
CONDITION OR RISK FACTOR | PROBABLE MECHANISMS |
---|---|
Maternal age at pregnancy or birth spacing practices | |
• Pregnancy at young age (<18 yrs) | • Increased risk of obstetric complications e.g. obstructed labour if young (<18) |
• Maternal age > 35 | • Increased risk of pregnancy induced hypertension in teenage pregnancies |
• Short interpregnancy interval | • Increased risk of congenital anomalies, particularly chromosomal defects, with advanced maternal age |
• Grand multiparity (> 4 prior pregnancies) | • Increased risk of gestational diabetes with grand multiparity |
Maternal nutritional status before pregnancy: | |
• Short maternal stature (<145 cm) | • Increased risk of feto-pelvic disproportion if malnourished in childhood |
• Undernutrition (low BMI/specific Micronutrient deficiencies (eg folate) | • Increased risk of neural tube defects with folic acid deficiency |
• Obesity | • Unknown pathways (e.g., obesity carries risk of gestational diabetes and pre-eclampsia, but mechanisms unknown) |
• Severe anaemia | |
Maternal medical conditions during pregnancy: | |
• Diabetes | • Uncontrolled diabetes may result in macrosomia and increased risk of obstructed labour |
• Hypertensive disorders (pre-eclampsia/eclampsia) | • Poorly controlled diabetes carries increased risk of congenital abnormalities |
• Cholestasis or other liver disease | • Placental dysfunction including abruption (hypertension), reduced fetal growth, increased risk of acute on chronic fetal hypoxia |
• Thrombophilias | • Placental abnormalities like intravascular thrombi, decidual vasculopathy and ischemic necrosis with villous infarctions (in thrombophilias) |
Exposure to harmful substances: | |
• Tobacco/alcohol/drug use | • Reduced fetal growth, increased risk of acute on chronic fetal hypoxia (increased fetal carboxyhemoglobin and vascular resistance with smoking and biomass fuels) |
• Cooking fires (biomass fuel) | • Increased risk of congenital abnormalities with exposure to certain toxins or drugs, including occupational exposure such as pesticides |
• Exposure to environmental toxins | |
Contextual factors: socioeconomic disadvantage and access to care, especially obstetric care: | |
• Poor access to healthcare services because of distance, and/or financial barriers | • Increased risk of obstetric complications e.g. obstructed labour if young (<18) and/or malnourished in childhood and/or FGM resulting in increased combined risk of feto-pelvic disproportion |
• Ethnic or religious minority affecting equal access to care | • Increased risk of infection and undiagnosed/untreated infections |
• Maternal illiteracy/low educational status | • Increased delays in accessing care |
• Female genital mutilation (FGM) | • Lack of quality emergency obstetric care even when care is accessed (e.g. no caesarean section or delay to time of section, or need for additional payments) |
• Inability to afford quality obstetric care | |
• Some risk factors are systematically associated with low socio-economic status (e.g., extremes of maternal age, extremes of body mass index, and smoking, alcohol and drug abuse) |
Losses that are socially invisible and remain a taboo
NUMERATOR – Stillbirths and early neonatal deaths are often hidden
|
• Loss of "not-yet-human" babies is attributed to spiritual possession and sorcery in many traditional cultures. Hence social norms suppress grieving or even discussion for fear of the spirits causing a recurrence. |
• In societies where fertility is prized, having a stillbirth may constitute failure as a wife and may result in divorce, adding a layer of shame to having had a stillbirth. |
• Lack of societal recognition of a stillbirth as a loss (e.g. compared to a child death) also results in suppressed grieving and lengthened time for grief resolution. |
• Women may fear being accused of having an induced abortion or not wanting the baby. |
• Some cultures believe a stillbirth occurs because the woman was unfaithful during pregnancy, so the event may be concealed to prevent gossip. |
DENOMINATOR – Pregnancy is concealed in many cultures
|
• Pregnant women are believed to be more vulnerable to sorcery, spirit possession, injury, and disease. Hence pregnancies are not publicly acknowledged until they "show" and may even be denied when very apparent (e.g., an Ashanti in Ghana when asked if pregnant is expected to say "No I am only drinking too much water"). In many cultures, disclosure is limited to one's partner and one or two trusted females to secure support. |
• In societies with high fertility and high rates of breastfeeding, women may not be menstruating regularly and may be several months pregnant before they are aware of the pregnancy. |
DATA IMPLICATIONS
|
• Underreporting of stillbirths and pregnancies is common in many settings. Sensitivity may be heightened where induced abortion is illegal or socially unacceptable. |
• Mortality data collection techniques are required that are more confidential and woman-sensitive. |
• An objective scoring system for stillbirth data quality is required so that falsely low rates are not used for programme priority setting and tracking of programme effectiveness. |
• Analysis suggests that existing data collections systems underestimate stillbirth rates (Vital Registration systems by 34% and Demographic and Health Surveys by at least 30%). Current data in many settings may need to be adjusted using modelling techniques. |
SOCIETAL IMPLICATIONS
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• Social taboos mean that open mourning, public discussion and also media coverage is rare, and this affects the policy priority given to stillbirths by the media and by politicians. |
Stillbirths – current epidemiology to guide action
GLOBAL DATA AND POLICY PRIORITIES |
• Tracking mortality reduction: Almost all (98%) of the world's 3.2 million stillbirths occur in low- or middle-income countries, yet stillbirths are rarely mentioned by global decision makers or United Nations Agencies. This is a missed opportunity for large scale maternal, newborn and child health (MNCH) investment programmes to track significant mortality benefit. Stillbirths should be included in mortality tracking wherever child and/or maternal outcomes are being assessed in household surveys or in health system or research evaluations. |
• Intrapartum priority: Given that 1 million stillbirths occur during the time of labour and that half of the world's births are in facilities, improved obstetric care offers an immediate opportunity to reduce these deaths and the linked 840,000 neonatal deaths that are intrapartum-related. However, many intrapartum stillbirths occur at home or on the way to a facility, so innovative approaches are required to address delays in accessing obstetric care. |
• Effective antenatal care: Around 2.2 million stillbirths occur during the last trimester but before the onset of labour. Given that over 75% of pregnant women globally access antenatal care (72% in Africa and 68% in South Asia), there are many missed opportunities for effective interventions to be provided through antenatal care. Priority conditions to address include pregnancy induced hypertension; antepartum haemorrhage; maternal infections such as syphilis, malaria and HIV; and obstetric risk conditions such as multiple pregnancy and abnormal lie. |
NATIONAL DATA AND PROGRAMME PRIORITIES
|
• In many high-income countries, stillbirth rates have not been declining at the expected rate. Improvements are possible with increased use of confidential enquiry data and attention to implement well what is known but also to innovate to address key challenges. |
• In middle-income countries, strengthening vital registration data for stillbirths and scaling up perinatal audit will give more data for priority setting and tracking of programme effectiveness. |
• In low-income countries, urgent attention should be given to how to better measure stillbirth rates in existing large-scale household surveys (for example the use of pregnancy history instead of birth history modules) and consideration of post-survey verbal autopsy to increase data on stillbirth cause of death. |
• In all country programmesfor maternal and neonatal health, when scaling up, specific attention should be paid to including high-impact interventions to reduce stillbirths and to tracking key indicators for quality of care such as intrapartum stillbirth rate. |
• Research studiesfor maternal and neonatal health outcomes should consider measuring and reporting stillbirth outcomes. |
Objectives and methods for this series of papers on stillbirths
Objectives
Methods for searches, abstraction and synthesis
Selection of specific interventions
Family and community norms and behaviours |
Prevention of female genital mutilation and management of pregnant women with FGM |
Birth spacing |
Reduction of exposure to indoor air pollution |
Smoking cessation |
Reduction of exposure to smokeless tobacco |
Antenatal care
|
Nutritional support during pregnancy
|
Periconceptional folic acid supplementation |
Iron supplementation |
Multiple micronutrient supplementation |
Vitamin A/beta-carotene supplementation |
Magnesium supplementation for deficient states |
Balanced protein-energy supplementation |
Prevention and management of problems in pregnancy
|
Management of hypertension in pregnancy |
‧Pregnancy-induced hypertension management: calcium and anti-hypertensives |
‧Anti-platelet agents in pregnancy |
Heparin and other anti-coagulants |
Anti-oxidants |
Management of intrahepatic cholestasis |
Plasma exchange |
Cervical cerclage |
Infection control and treatment
|
Syphilis screening and treatment |
Antibiotics and anti-sepsis for high-risk pregnancies (asymptomatic bacteriuria, bacterial vaginosis and GBS colonisation) |
Antibiotics for preterm rupture of membranes |
Anti-helminthics |
Prophylactic anti-malarials |
Insecticide-treated nets |
Prevention of mother-to-child transmission of HIV |
Periodontal care |
Advanced monitoring and care during pregnancy (Paper 4 [11]) |
Identification and care of high-risk pregnancies
|
Pregnancy risk screening |
Fetal movement monitoring |
Ultrasound scanning |
Doppler monitoring in high-risk pregnancy |
Pelvimetry |
Detection and management of maternal diabetes mellitus |
Advanced monitoring in pregnancy
|
Antepartum fetal heart rate monitoring with cardiotocography |
Fetal biophysical test scoring |
Vibroacoustic stimulation |
Amniotic fluid volume assessment |
Home versus hospital bed rest and monitoring for high risk pregnancies |
In-hospital fetal surveillance unit |
Monitoring during the intrapartum period
|
Use of the partograph |
Cardiotocography with or without pulse oximetry |
Interventions during childbirth (intrapartum) (Paper 5 [12]) |
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Instrumental delivery (vacuum and forceps-assisted) |
Emergency obstetric care, including Caesarean section |
Induction of labour versus expectant management |
Drugs for cervical ripening and induction of labour |
Planned Caesarean for breech presentation |
Magnesium sulphate for treatment of PIH/eclampsia or preterm labour |
Maternal hyperoxygenation for suspected impaired fetal growth |
Amnioinfusion |
Cross-cutting issues in the prevention of stillbirths (Paper 6 [13]) |
Community demand creation strategies
|
Emergency loan and insurance funds for emergency obstetric care |
Financial incentives for care seeking |
Supply side capacity building (especially human resources development)
|
Training of traditional birth attendants in clean delivery and referral |
Training of other cadres of community health workers |
Training nurse aides (including task-shifting) as birth attendants |
Training to improve skills of professional midwives in antenatal and intrapartum care |
Obstetric drills |
Training in neonatal resuscitation for physicians and other health care workers |
Health system organizational strategies
|
Public-private partnerships to provide emergency obstetric care |
Maternity waiting homes |
Home birth with skilled attendance versus hospital birth for low-risk pregnancy |
Perinatal audit
|
Grading of evidence
Assessment of individual studies | Grade |
---|---|
High quality meta analysis, systematic review of randomized controlled trials (RCT), or RCT with very low risk of bias | 1++ |
Well-conducted meta analysis, systematic review of RCTs, or RCT with a low risk of bias | 1+ |
Meta analysis, systematic review of RCTs, or RCT with a high risk of bias | 1- |
High quality systematic reviews of case-control or cohort studies High quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal | 2++ |
Well conducted case control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal | 2+ |
Case control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal | 2- |
Non-analytic studies, e.g. case reports, case series | 3 |
Expert opinion | 4 |
Assessment of all evidence for each intervention
|
Grade
|
At least 1 meta analysis, systematic review, or RCT rated as 1++, directly applicable to the target population; or a systematic review of RCTs or a body of evidence consisting primarily of studies rated as 1+, directly applicable to the target population and demonstrating consistent overall results | A |
Body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating consistent overall results; or extrapolated evidence from studies rated as 1++ or 1+ | B |
Body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating consistent overall results; or extrapolated evidence from studies rated as 2++ | C |
Body of evidence 3 or 4; or extrapolated evidence from studies rated as 2+ | D |