Protecting families from recurrent stillbirthBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h3262 (Published 24 June 2015) Cite this as: BMJ 2015;350:h3262
- Alexander E P Heazell, senior clinical lecturer in obstetrics and clinical director1,
- Jane Clewlow, parent2
- 1Tommy’s Maternal and Fetal Health Research Centre, St Mary’s Hospital, University of Manchester M13 9WL, UK
- 2Rainbow Clinic, St Mary’s Hospital, Manchester, UK
- Correspondence to: A E P Heazell
Stillbirth is a tragedy for parents and has enduring medical, psychological, social, and economic consequences. It remains a major problem in the United Kingdom; in 2013, 3286 babies were stillborn after 24 weeks of pregnancy, equating to one in every 240 births.1 Since 2011, when the UK was ranked 33rd out of 35 high income countries for stillbirths, there has been a downward trend in the stillbirth rate, but this has not yet reached the lower levels seen in Scandinavia or the Netherlands.2
Identification of pregnancies at increased risk of stillbirth can help to prevent stillbirths by directing additional antenatal care and intervention to those most likely to benefit. Consequently, identification of risk factors is highly desirable.
In their meta-analysis of 16 studies of 3 412 079 women in this issue, Lamont and colleagues (doi:10.1136/bmj.h3080) identify an increased risk of stillbirth in subsequent pregnancies after a previous pregnancy ended in stillbirth.3 This approximately fivefold increase in risk is greater than that of stillbirth associated with pre-existing medical conditions, such as diabetes or hypertension.4 Heightened antenatal surveillance is recommended in both of these maternal conditions and should be considered for women with a previous stillbirth.
Stillbirth has a variety of causes, only some of which, such as placental insufficiency, are likely to influence the risk in subsequent pregnancies. Other causes, such as umbilical cord occlusion are thought to be isolated. A substantial proportion of stillbirths (around 20%) remain unexplained.5 6 7 Lamont and colleagues were unable to explore the contribution of specific causes of stillbirth to risk in a subsequent pregnancy.3 If heightened surveillance is recommended for pregnant women with a history of stillbirth, it should be offered to all affected women not just those with an identifiable and potentially recurring cause.
In common with other international studies of stillbirth, Lamont and colleagues’ meta-analysis was limited by variations in the definition of stillbirth within individual studies, the classification system used, and the extent of adjustments for confounding factors. This may in part explain the considerable heterogeneity in their findings. To facilitate meaningful international comparisons, future research would benefit from standardisation in the definition and classification of stillbirth. An “unexplained” stillbirth should be reserved for those stillbirths without an identifiable cause despite thorough investigation, and they should not include those events that remained unexplained after inadequate or incomplete review. Most studies in Lamont and colleagues’ meta-analysis did not report rates of postmortem examination, placental histology, or chromosomal analysis, all of which reduce the proportion of stillbirths defined as unexplained. Without this kind of information, readers cannot deduce whether reported stillbirths were truly unexplained. Rates of postmortem examination continue to fall in the UK, a worrying trend that reduces the ability to identify or exclude recurrent causes of stillbirth.
Current guidance from the UK’s Royal College of Obstetricians and Gynaecologists recommends that women with a previous stillbirth are managed as high risk during a subsequent pregnancy.8 Lamont and colleagues provide a biomedical basis for this recommendation. The need for specialist care should also take into account the additional psychological needs of parents during pregnancies that follow a stillbirth; a metasynthesis of parents’ experiences highlighted the challenges of subsequent pregnancies, particularly for mothers.8 During pregnancy, conflicting emotions may co-exist as hope for the forthcoming pregnancy combines with grief and profound anxiety. Women who have experienced stillbirth may doubt that their bodies can sustain healthy pregnancies. To cope, parents may delay emotional attachment with their baby, or seek additional control. Interactions with health professionals gain heightened importance and may in themselves be therapeutic; additional support from health professionals is valued highly by parents.9
The death of a child is a life changing event that may occur with no warning signs or symptoms. Women can believe their body has let them down, and also feel guilty that they had not protected their child, or given their family another child. Parents recognise that the support they need in a subsequent pregnancy differs from that needed and received previously. Continuity of care by the same provider, and additional ultrasound scans provide parents with reassurance that their concerns will be heard and deviations from a healthy pregnancy detected. However, even these interventions do not remove the anxiety associated with a late stillbirth because there are no thresholds to reach, no point at which a stillbirth can be ruled out. Rather than trying to prevent or hide anxiety, care in a service dedicated to parents with a history of stillbirth exposes parents to other families with similar experiences and emotions, avoids awkward questions, and helps reduce feelings of isolation.
Despite the psychological and emotional upheaval, most women embark on another pregnancy after a stillbirth; 50% of whom do so within one year.10 A substantial proportion of women using maternity services will have had a stillbirth in the recent past. Lamont and colleagues estimate that 8% of stillbirths are attributable to the risks associated with a previous event (population attributable risk),3 which suggests that effective antenatal surveillance and intervention for this high risk group may reduce the overall burden of stillbirth. However, the authors stress that we still do not know whether the potential benefits of increased surveillance outweigh the potential harms to babies or mothers from unnecessary interventions. Critically, over 1100 parents and professionals contributing to the stillbirth Priority Setting Partnership identified care in a subsequent pregnancy as one of the top priorities for stillbirth research.11
Lamont and colleagues’ findings add to previous evidence that pregnancies after a stillbirth should be managed as high risk. Precisely how that should be done to optimise biomedical and psychological outcomes for families is not yet clear. Finding out should be an urgent priority for researchers and clinicians.
Cite this as: BMJ 2015;350:h3262
Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following: none.
Provenance and peer review: Commissioned, not peer reviewed