Why do stillbirths occur?

JOY LAWN: So why do stillbirths occur? Well, unlike for newborn deaths, we have a problem with putting together the data. And the critical problem here is that there are more than 35 classification systems for understanding stillbirths. In fact, it seems to me that every time a male obstetrician has a rite of passage, they decide to invent a new classification system. But despite this problem with the classification systems, there are clearly five leading causes of stillbirths around the world.

And the first one and the hugest one and the one that should be most unacceptable is that of childbirth complications– so more than 1 million babies every year, where the woman starts labour with a kicking, live baby and that baby dies during labour. This is something that’s rare in high-income countries, and yet not only does it happen more than a million times a year around the world, but in fact, we are very poor at counting these deaths. So in our new estimates with WHO for stillbirth rates, we found considerably more data. And yet there are still more than 100 countries that lack data for intrapartum stillbirth rates– something that should be unacceptable.

And not only is it happening, but it’s happening without us counting it properly. The second leading cause of stillbirths are maternal infections. And one critical and highly preventable one that we would like to highlight here is syphilis. So if you just count syphilis in neonatal deaths, it’s a small proportion, relatively, about 70,000. But there are probably at least 200,000 stillbirths every year from maternal syphilis, something that we’ve had the solution to prevent for many decades. So this is an issue of quality of antenatal care. The next one, the third cause, is around non-communicable diseases in women, so hypertension, diabetes.

And these link through the pathway of foetal growth restriction, which is an important and slightly more challenging detection problem that is really critical to address in stillbirths. And the final direct cause of stillbirth is congenital abnormalities. And in many societies, people still have this belief that all stillbirths were meant to be, that most of them were due to severe congenital abnormalities. And in new data and analysis across more than 20 countries with comparable data and with comparable policies for termination of pregnancy for abnormalities, we can see that a median of just over 10% are due to congenital conditions. So these are important.

They are some that are very preventable, for example, neural tube defects, where folic acid supplementation was a critical and very low-cost way of preventing these abnormalities. But what we’d like to highlight here is stillbirths do have specific causes and that most of those causes are causes that can be prevented.

And also in high-income countries where we have good quality of perinatal audit, what we see is that around 30% of stillbirths– so this is in settings where there are few stillbirths, maybe less than five per thousand, and around 30% of those are still identified as having preventable actions, actions that should’ve been taken to prevent these and that are highlighted in audit as something should’ve been done differently, often within the health system to prevent the stillbirths.