Maternity

COUNTING THE COST OF STILLBIRTHS
On the 14th April 2011 The Lancet published a series of ground-breaking online articles on an issue that is not only invisible in the majority of societies around the world but is ignored on international policy, programme and investment agendas. The issue is stillbirth, a devastating event for millions of women and their families every year, and one that the series of articles in The Lancet identified as one of the most shamefully neglected areas of public health.

Stillbirth is not counted in the Millennium Development Goals; it is not counted by the United Nations (UN); nor is it counted in the Global Burden of Disease figures. This despite the fact that in 2008 there were an estimated 2.65 million stillbirths with over a million of them occurring intrapartum – during labour and birth. The international definition of stillbirth is the death of a baby after 28 weeks gestation.

Most intrapartum stillbirths are associated with obstetric emergencies, whereas deaths during the third trimester of pregnancy are associated with maternal infections and foetal growth restriction.

In the first of six papers about stillbirth entitled “Stillbirths: why they matter,” Dr J Frederik Froen and his colleagues report:
“To be registered, counted and recognised also has profound humane implications. Although stillbirth can be as devastating as a child’s death, often the baby is known and mourned solely by the parents. Even in high-resource settings in which psychological support might be available, one in five mothers has appreciable long-term depression, anxiety, or post-traumatic stress disorder after a stillbirth. Fathers are also affected by negative psycho-social consequences. When compared with the leading global causes of death in all age categories, all-cause stillbirths would rank fifth among the global health burdens – before diarrhoea, HIV/AIDS, tuberculosis, traffic accidents, and any form of cancer.” (1)

The focus on maternal health
Over the past few decades there has been an increasing focus on maternal and child health which has seen a number of significant initiatives and interventions. Despite this, stillbirths have been ignored and the loss of these babies remains largely invisible.

For example, in September 2010, the UN summarised the commitments to improve maternal and child health by seven UN agencies, 36 countries, and more than 75 non-governmental organisations (NGOs) and professional organisations: stillbirth is not mentioned in any of them.

Stillbirths linked to deprivation
98% of stillbirths occur in countries of low and middle incomes, and within high-income countries disadvantaged populations have a much greater risk of stillbirth than affluent populations. The five major causes of stillbirths in low and middle income countries are childbirth complications, maternal infections during pregnancy (syphilis), maternal disorders (especially hypertension), maternal under-nutrition and foetal growth restriction, and congenital abnormalities. 

The variation in stillbirth rates across and within high-income countries indicate that further reduction in stillbirth is possible in these countries as well. While stillbirth rates have declined dramatically from around 1940, over recent times the decline has slowed or even stalled. (2) 

In most countries the causes of stillbirths are inseparable from those that result in the deaths of pregnant women and their newborn babies. The Millennium Development Goals estimate that there are 350,000 maternal deaths and 3.6 million neonatal deaths every year. In countries with high mortality rates, emergency obstetric care has the greatest effect on these deaths, as well as on stillbirths. (3)

High-income countries
In high-income countries the familiar link between low socioeconomic status and adverse outcomes are starkly evident with large increases in the risk of stillbirth in minority populations. Inuit-inhabited areas of Canada have almost three times the rate of stillbirths as compared to the rest of Canada. Indigenous Australia women have almost twice the risk of non-indigenous women, as do African-American women in the USA when compared with white women. Reports from the UK and New Zealand reveal a similar scenario. (2)   

Other risk factors
Smoking is a major contributor to stillbirths in some disadvantaged populations. For example, among indigenous Australian and Canadian women smoking contributes to about 20% of stillbirths compared with 4-7% overall in high-income countries.

Obesity is another major and potentially modifiable risk factor for stillbirths.  

Other risk factors include:
• A maternal age of more than 35 years
• Alcohol consumption during pregnancy
• A first pregnancy
• A previous caesarean birth
• A multiple pregnancy
• Use of reproductive technology
• Lack of antenatal care

Call to action
The sixth paper in the series calls for high-income countries to eliminate all preventable stillbirths and close equity gaps. By 2020 low income and middle income countries should aim to have reduced their current stillbirth rates by at least 50%.

However, first stillbirths need to be recognised by all countries and the UN as a major public health issue. Then each stillbirth must be counted.

References
1. J. Frederik Froen et al. “Stillbirths: why they matter.” www.thelancet.com 14 April 2011.
2. Vicki Flenady et al. "Stillbirths: the way forward in high-income countries.” www.thelancet.com 14 April 2011.
3. Robert Pattinson et al. “Stillbirths: how can health systems deliver for mothers & babies?” www.thelancet.com 14 April 2011.