Falls in stillbirth rates since the year 2000 are failing to keep pace with falls in childhood and maternal mortality rates, according to a series of research papers.
While 98% of stillbirths occur in low-income and middle-income countries, they also remain a problem for high-income countries, highlighted the authors of the studies published in The Lancet.
“In the UK, there is still much to be done to ensure our rate of progress is as good as the best in Europe”
One study, by the London School of Hygiene and Tropical Medicine, found that from 2000 to 2015, the global average stillbirth rate fell from 24.7 per 1,000 total births to 18.4 – equivalent to an annual rate of reduction of 2% for stillbirths.
“Although some progress has been made, this reduction has been slower than for maternal (ARR 3%), neonatal (3.1%), and post-neonatal mortality of children younger than five years (4.5%) over the same period,” they said.
The studies also provided new findings on the preventability of stillbirths. Data from 18 countries suggested that congenital abnormalities account for a median of only 7.4% of stillbirths, dispelling the myth that all stillbirths are inevitable and due to congenital conditions.
Many disorders associated with stillbirths were modifiable and often co-exist, such as maternal infections, non-communicable diseases, nutrition and lifestyle factors, and maternal age older than 35 years, said researchers.
Pre-eclampsia and eclampsia together contribute to 4.7% of stillbirths, while prolonged pregnancies contribute to 14% of stillbirths.
The study authors highlighted countries that had made impressive progress. A 6.8% reduction in the Netherlands was attributed to improvements in antenatal care and care at birth, a wide-scale perinatal audit, coupled with a focus on women’s health before and during pregnancy.
However, they highlighted that stillbirths remain a problem in other high income countries, with variations in rates across countries and large equity gaps persisting.
Researchers from the University of Queensland in Australia warned that data suggested substandard care contributes to 20-30% of all stillbirths in high income countries.
They noted that stillbirth rates for women of South Asian and African origin giving birth in Europe or Australia were two to three times higher than white women.
They called for education and the alleviation of poverty, as well as improved access to healthcare, especially timely, culturally appropriate antenatal care.
The researchers also called for national perinatal mortality audit programmes to be implemented in all high-income countries, including a systematic approach to classifying the causes of stillbirth and research focusing on prediction, understanding placental pathways to stillbirth and causal pathways to unexplained stillbirth.
They added that interventions to increase the number of women beginning pregnancy with a normal bodyweight were crucially important to improve pregnancy outcomes and longer-term health.
“The UK needs to do more to address health inequalities and to reduce stillbirths in areas of social deprivation”
Meanwhile, researchers from St Mary’s Hospital in Manchester highlighted the implications of stillbirths on parents, families, health-care providers and societies worldwide.
They estimated that 60-70% of grieving mothers in high income countries reported grief-related depressive symptoms that they regarded as clinically significant one year after their baby’s death. In about half of cases, these symptoms endured for at least four years after the loss.
The authors said: “The key element of what works to reduce the impact of stillbirth on bereaved parents and families can be summarised as seeing through the eyes of those affected. This includes staff who understand what different parents and families need and when they need it.”
Dr David Richmond, president of the Royal College of Obstetricians and Gynaecologists, said: “This comprehensive series of papers presents a ‘wake-up call’ to governments worldwide to make faster progress in reducing the number of stillbirths.
“In the UK, there is still much to be done to ensure our rate of progress is as good as the best in Europe,” he said. “We are committed to understanding more about stillbirths, improving multi-disciplinary training packages and promoting more effective team working to help doctors and midwives pick up potential complications and reduce the number of babies who are stillborn.”
Dr David Richmond
“We have also identified that local reviews following stillbirth remain an area in need of clear improvement,” he said. “Through the RCOG’s Each Baby Counts initiative, we are this year beginning to undertake a structured review of each and every stillbirth that occurs during labour in term pregnancies to help identify common risk factors, learn from what went wrong and apply the lessons in maternity units across the country.
“Promotion of messages which may help women reduce the risk of stillbirth – such as maintaining a healthy weight prior to conception, stopping smoking and attending antenatal appointments – are all essential components to help end preventable stillbirths worldwide,” he said.
“Additionally, the messages within the recent MBRRACE stillbirth review in the UK – which include recognising risk factors for gestational diabetes and implementation of recommendations for care, measuring and recording of growth as well as foetal movements – are just as relevant globally as they are here in the UK,” said Dr Richmond.
Louise Silverton, director for midwifery at the Royal College of Midwives, added: “This is a welcomed report, but looking at it from a UK perspective it is disappointing.
“Attention to preventing stillbirths in approach to term and 36 weeks plus must be improved,” she said. “The UK needs to do more to address health inequalities and to reduce stillbirths in areas of social deprivation.”
“Access to smoking cessation services for fathers and other family members could help women to stop smoking reducing risks of both stillbirth and improving the health outcomes for the baby after birth,” said Ms Silverton.