Towards an end to stillbirthsBMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c5070 (Published 06 October 2010) Cite this as: BMJ 2010;341:c5070
- Alexander E Heazell, clinical lecturer in obstetrics, University of Manchester
“I am sorry: I cannot see your baby’s heart beating” are words that parents do not expect to hear. There was no mention of stillbirth in popular books about pregnancy, no suggestion in the shopping catalogues full of smiling babies. I am a doctor, so even though I was aware that pregnancy was not risk free, I did not expect my own unborn child to die. I now realise that our son is one of many such deaths, and the impact of stillbirth is greater than anyone seems to recognise.
On average there are around 10 stillbirths every day in the United Kingdom and more than 4000 a year, the equivalent of a year’s births in many hospitals. The worldwide burden is estimated at 3 000 000 stillbirths a year, 99% of which are in the developing world.1 In the UK the rate of stillbirths has not fallen significantly for more than a decade, remaining at 5.3 per 1000 live births.2 In the same period advances in neonatal care have seen neonatal deaths fall from 4.1 to 3.4 per 1000.2 3 Deaths of infants during labour account for 7.8% of the total number of stillbirths in the UK2 but two thirds of associated litigation, and the number has been falling in recent years.4 However, numbers of antepartum stillbirths, which represent the bulk of perinatal mortality, remain unchanged. A recent multinational review proposed that this lack of progress resulted from a dearth of studies aiming to reduce the impact of stillbirth.5 So why is stillbirth, which affects one in 200 parents, so under-researched and underprioritised?
It isn’t just health professionals who see stillbirth as rare and insignificant. A survey of the general public showed that most people think that Down’s syndrome is more common than stillbirth (the risk of the syndrome is in fact one in 700). Cot death, which is at the forefront of every expectant parent’s mind, is 10 times less common than stillbirth.6 The invisibility of stillbirth is compounded by the reluctance of professionals and parents to deal with stillbirth openly; often a stillbirth is locked away, an unspeakable and private loss. Many obstetricians and midwives enter their profession to be involved in the extraordinary experience of the beginning of life, not the harrowing combination of death at birth. Where stillbirth is diagnosed before birth, most women give birth vaginally, providing challenges to intrapartum care for midwives and obstetricians. For parents this is a devastating and confusing time that nothing and no one has equipped them to deal with. Many want to see and hold their child and have someone validate their feelings. Physical evidence of hair, photographs, and footprints can help provide mementos for parents, confirming the existence of their child.7 The negative psychological and social consequences of stillbirth, including anxiety disorders, depression, and relationship breakdown, often result from a lack of acknowledgment of life and of loss.
Two constant findings in published reports on stillbirth challenge clinicians’ views of modern medicine. Firstly, most stillbirths remain unexplained, an anachronism in a time when evolving genetic and biological technologies are constantly improving the diagnosis of disease. The admission that we cannot explain stillbirth leads us to the uncomfortable conclusion that we don’t know everything. It also follows that we have little to offer parents in subsequent pregnancies, save for increased surveillance, to minimise their risk of another stillbirth, which is twofold to 10-fold greater than in women with a live born child.
In many cases stillbirth also represents a perceived failure of maternity care, which is designed to deliver a healthy baby to its parents. Recently health care has been driven towards achieving clinical excellence. In contrast, the care of women with stillbirth is associated with multiple shortcomings—those leading to the stillbirth and in how parents are cared for afterwards. A recent study found suboptimal care in 45% of stillbirths.8 By focusing on excellence there is a temptation, whether subconscious or not, for clinicians to regard as beyond salvage those areas where clinical care has long failed to make an impact.
Finally, and perhaps of greatest consequence to policy makers, stillbirth is not solely a medical or midwifery matter. Many of the factors associated with stillbirth are outside the realms of medical care. Poverty, educational attainment, smoking, alcohol and drug misuse, and lack of appropriate birthing facilities all affect the risk of stillbirth. This health inequality is not restricted to the developing world. Perinatal mortality is 50% greater in the most deprived areas of the UK.9
How then do we tackle a tragedy such as stillbirth when the problem is so complex? I think the time has come to end the silence surrounding stillbirth. Stillbirth needs to be prioritised by government, support groups, and those in maternity care. For improvements to be made policy makers must recognise the impact of stillbirth and the need for research to develop strategies to prevent it and its consequences for parents. There is currently a funding gap to provide such research. In 2008-9 in the UK £2.2m (0.33% of the budget of the UK National Institutes of Health Research) was spent on “research related to stillbirth.”10 11 This shortage of funding becomes even more apparent when you look at research activity; in the UK only 39% of medical schools and 4% of midwifery colleges are conducting research related to stillbirth. This research gap is more evident in the literature; “stillbirth” yields 4012 hits on PubMed, whereas “pregnancy” yields 666 789.
Thirty years ago no one talked about cancer. Today the diagnosis and treatment of cancers are improving all the time. If parents are brave enough to speak, and doctors, midwives, and policy makers courageous enough to listen to them, then the barriers to reducing the number of these deaths can be overcome. In time stillbirth, like cancer, will no longer be taboo but a condition that’s openly debated, researched, treated, and prevented.
Cite this as: BMJ 2010;341:c5070
Competing interests: AEH holds two grants from the Tunbridge Wells group of the UK Stillbirth and Neonatal Death Society to investigate the role of the placenta in stillbirth and the care of parents after perinatal loss.