Maternal and fetal risk factors for stillbirth: population based study
BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f108 (Published 24 January 2013) Cite this as: BMJ 2013;346:f108
All rapid responses
Editor -
On behalf of my co-authors, I would like to thank your correspondents for their interest in our paper, and would like to respond to several points which relate to our study.
Vlachadis & Kornarou (4 February) discuss the association between maternal age and stillbirth which did not reach significance in our univariate analysis, but may, they claim, do so if <25 and 35+ groups were added together. This may be the case, but is unlikely to help in our understanding of underlying causes, as they are likely to be linked to different pathological mechanisms. For example, young mothers are more likely to be smokers, and older mothers are more likely to be obese or have gestational diabetes or hypertension. Each of these came out as significant risk factors for stillbirth in the multivariable analyses, but maternal age did not, after these variables were adjusted for.
Hemming and Lilford (15 February) appear to be interpreting our report as suggesting that GROW software is the sole answer for reducing stillbirths with fetal growth restriction. In fact the only context within which we mention GROW (gestation related optimal weight) software is as the tool we used to calculate the birthweight centiles in our cohort. This standard is based on growth potential and therefore helps to distinguish physiological and pathological smallness.
The same principle can be applied prospectively in antenatal GROW charts, which have been shown to improve antenatal detection of growth restriction, while reducing unnecessary investigations for small-normal babies. However a reduction in stillbirths is unlikely to be achieved just by using one type of chart in preference to another; it will require standardised measurement and plotting of fundal height in low risk pregnancy, agreed referral pathways, training to improve recognition of risk factors, sufficient ultrasound resources for high risk pregnancies, agreed protocols for serial scanning, and uniformly implemented guidelines for mode of investigation and timing of delivery of affected babies. Regrettably none of these aspects of care are currently standardised, and an RCT would not only need to control for all of them, but also be quite substantial in size, if it wanted to evaluate the benefit of the growth chart alone.
Gupta and Jani (15 February) raise the important issue of gestational age in relation to stillbirth. In Fig 2 of our paper, we compared the gestational age at birth for live births and stillbirths with and without fetal growth restriction, and demonstrated that stillbirths in general, and more so those with fetal growth restriction, delivered much earlier. Intrapartum related deaths represent about 10% of stillbirths in our population, but they indeed account for a much larger proportion in developing countries, and prematurity as well as fetal growth restriction represent significant risk due to diminished fetal reserve and related factors.
Competing interests: No competing interests
As a researcher of stillbirths for 5 years now I have concerns about the following:
1. Infant death classification and registration – Outdated information not shared, stillbirth causation must change if we are to reduce stillbirths, if we don’t know the cause we can’t prevent.
2. Labelling any pregnancy Low Risk – Global Research Higher Mortality
3. NHSLA (Litigation) – now costing hundreds of millions
4. Infant deaths increase between the hrs 8pm > 6am and weekends – Oxford University
5. Research indicates 70%> of term stillbirths are preventable – Hidden
6. Parent birthing information and stillbirth prevention – Seriously Lacking
7. Current antenatal protocols and screening – Lacking
8. Introduction of keeping childbirth natural & dynamic – RCM how is this applied.
9. NHS staff in training – Unsupervised
10. The tendency to apply limits to C-Section – yet WHO retracted limiting CS – Clearly our babies are now on the larger side and many mums have babies later in life thus the increase with clinical issues that can be life threatening to mother and baby.
The list above is not directed any individual or organisation mainly the facts surrounding many stillbirths.
Competing interests: No competing interests
The gestational age of a baby at birth is an important determinant of its survival, including the causation of stillbirth. There is no mention of it anywhere in the article.
Intrapartum deaths are a major cause of stillbirth in developing countries which is largely avoidable. Foetal growth restriction is, as the paper says, an important factor. However, prematurity, as universally acknowledged, is a risk factor for stillbirth in both developed and developing countries.
Competing interests: No competing interests
In a population based observation study, it is suggested that improving the detection of intrauterine growth restriction (essentially by using the GROW software, developed by Jason Gardosi) could lead to 600 fewer stillbirths each year in the UK [2].
Whilst it certainly is the case that results from this observational study show that infants identified as having fetal growth restriction antenatally have a reduced risk of stillbirth (compared to those detected antenatally), observational evidence cannot replace robust randomised evidence. The DIGITAT [1] randomised equivalence trial in 321 women showed that, for singleton term pregnancies, with suspected intrauterine growth restriction, that induction had no impact on the composite outcome (death, APGAR <7, umbilical artery pH < 7.05 or admission to ICU). Whilst effects might be different at preterm weeks, randomised evidence of early prompt diagnosis and active surveillance is needed [3].
It is also claimed that the risk factors of maternal obesity, smoking and intrauterine growth restriction explain the “majority” of the normally formed stillbirths. Yet, to make such a claim the percentage of variation explained or some measure of discrimination (area under receiver operating curve) or calibration should be evaluated. This paper therefore does not inform whether these identified risk factors can predict the majority of stillbirths.
The software GROW might be able to identify infants with intrauterine growth restriction, but there will certainly be some miss-diagnoses; that is identification of fetuses as having fetal growth restriction which are actually growing appropriately. In the extreme case, surveillance and monitoring of fetuses with suspected intrauterine growth restriction might lead to induction; which in the case of miss-diagnoses will be at the risk of harm.
Whether 600 stillbirths could be avoided each year in the UK, by improving the detection of fetuses with intrauterine growth restriction, by essentially using the software GROW is debatable. Randomised evidence at term seems to suggest that induction in such cases will not necessarily be of benefit. Maybe it is time we had randomised controlled trials of GROW to determine whether it can live up to its claims. Trials would need to be very large to detect small effect sizes, perhaps prohibitively so, but if effect sizes are as large as suggested here, then such trials might well be feasible.
[2] Gardosi J, Madurasinghe V, Williams M, Malik A, Francis A. Maternal and fetal risk factors for stillbirth: population based study. BMJ. 2013 Jan 24;346:f108. doi: 10.1136/bmj.f108.
[1] van Wyk L, Boers KE, van der Post JAM, et al. Effects on (neuro)developmental and behavioral outcome at 2 years of age of induced labor compared with expectant management in intrauterine growth-restricted infants: long-term outcomes of the DIGITAT trial. Am J Obstet Gynecol 2012;206:406.e1-7.
[3] Grivell RM, Wong L, Bhatia V.Regimens of fetal surveillance for impaired fetal growth. Cochrane Database Syst Rev. 2012 Jun 13;6:CD007113. doi: 10.1002/14651858.CD007113.pub3.
Competing interests: No competing interests
In his Rapid Response above,(1) Dr. Vlachadis talks about the recent increase in Greece’s stillbirth rate. Following an historic low of 3.31 in 2008, by 2010 it had increased by 32% to 4.36. Vlachadis suggests this increase is likely associated with the country’s economic crisis, and increasing numbers of pregnant women being excluded from obstetric care. But there was another, possibly coincidental, occurrence around this time too. In 2008, a concerted effort began to inform Greek women about the benefits of natural birth; a new organization was formed(2), researchers wrote about “the CS epidemic” and “importance of performing more vaginal birth after CS”,(3) and Greek midwives called for “reorganizing the health education antenatal services”; they described “frightened women” as “obedient consumers” who were “products of a technocratic medical system [and] likely to choose intervention”.(4) Three years later, a shift away from intervention was reportedly(2) “not a particularly strong trend”, but shifting “mostly due to the crisis, because some benefits for birth in public hospitals and under the national health system have been cut.”
Certainly the culture of caesarean birth in Greece is somewhat unique. Greek mythology tells the story of Asklepios, the god of medicine whose mother died in labour, but whose father Apollon ‘rescued’ him by cutting him from her womb(5), and the word tokophobia stems from the Greek ‘ tokos’ and ‘phobia’, which mean birth and fear. Most notably, Greece is reported to have very high caesarean rates,* especially in the private sector,(2) but it’s the types of caesareans that is perhaps most interesting. In a 2011 university hospital study,(6) an overall caesarean rate of 29.2% over five years consisted of 18.2% elective and 11% emergency. That’s a reversal of England’s much lower 10.2% elective and higher 14.8% emergency rates,(7) and furthermore, just 6% of births were instrumental deliveries, compared with our 13%. This is important because this Greek hospital is managing to keep its riskiest births to a minimum.
Conversely, the ratio of obstetricians to pregnant women is reportedly far greater in Greece than here, with numbers historically rising alongside a falling birth rate.(8) By comparison, and despite 2004 British research that a “higher intervention score and higher number of consultant obstetricians per 1000 births were both independently and significantly associated with lower stillbirth rates”(9), the UK doesn’t have nearly enough obstetricians, and birth rates are increasing. Finally, Greece has one of the lowest maternal mortality rates in the world, and in 2010, with just 3 deaths per 100,000 live births, it ranked joint second out of 183 countries.(10)
Yet in 2011, an Organisation for Economic Co-operation and Development report began, “caesarean delivery continues to result in increased maternal mortality, maternal and infant morbidity, and increased complications for subsequent deliveries.”(11) In its report, the OECD lists the lowest caesarean rate (14.3%) as being in the Netherlands, and specifically mentions its 30% homebirth rate for “low risk” women. Greece’s caesarean rate is absent from the list, but so is the fact that in 2009, the Netherlands had one of the highest perinatal mortality rates in Europe (9.8 infant deaths in every 1000 live births), and was one of three named countries to have utilized the category of “unknown” most heavily (18.8%), in answer to why maternal deaths occurred.(12)
This is all very important in light of recent maternity care recommendations in the UK, emphasizing the need for higher rates of ‘normal’ birth, and lower rates of medical intervention (unless the intervention aids vaginal birth, i.e. instrumental delivery, but certainly fewer caesareans and epidurals),(13) and the fact that the 2011 Birthplace study, which is being passionately communicated to women to encourage birth outside obstetric units, excludes rates of stillbirth prior to onset of labour.(14)
That said, the decision about when to do a caesarean can undoubtedly be a difficult one; for those women with very high BMIs for example, the 40% and 60% increased stillbirth risk(1) must be weighed against the maternal risks associated with surgery. Similarly, the risk of stillbirth versus preterm morbidity is challenging too. Researchers have described increasing rates of late preterm births in Greece as a “rising concern”, although stillbirth rates fell in a constant way regardless of the maturity index.(15) Meanwhile in the U.S., a policy limiting elective delivery before 39 weeks of gestation “was associated with a small reduction in NICU admissions; however, macrosomia and stillbirth increased."(16)
It is not the aim of this response to present Greece, or high caesarean rates, as an ideal model of maternity care, but rather to highlight the need to look beyond blanket caesarean rates as an inherent value or marker for good health outcomes, and the need for stillbirth research to step outside its comfort zone. Caesarean league tables should be made redundant, unless they can specify emergency and planned rates alongside other critical facts such as perinatal and maternal mortality. And this is because for most women, what matters more than anything else is that their pregnancy ends with a live, healthy baby.
*the European Statistical Data Support Centre of Greece advised me that the country’s caesarean rate is not available through its service.
References
1) February 4, 2012 Increase of stillbirth rate in Greece. http://www.bmj.com/content/346/bmj.f108/rr/628738
2) December 8, 2011. “Greece ranks first in the world in number of Caesarean births”, Anastasia Balezdrova. GRReporter http://www.grreporter.info/en/greece_ranks_first_world_number_caesarean_...
3) Aust N Z J Obstet Gynaecol. 2008 Apr;48(2):142-6. doi: 10.1111/j.1479-828X.2008.00839.x. Current caesarean delivery rates and indications in a major public hospital in northern Greece. Dinas K, Mavromatidis G, Dovas D, Giannoulis C, Tantanasis T, Loufopoulos A, Tzafettas J. http://www.ncbi.nlm.nih.gov/pubmed/18366486
4) Caesarean Section: The Underpinning Choice? Vivilaki, Antoniou. Volume 2, Issue 2 (2008) HSJ http://www.hsj.gr/volume2/issue2/Caesarean_Section_The_Underpinning_Choi...
5) The Theoi Project : Greek Mythology. Aaron J. Atsma, Auckland, New Zealand. 2000–2011. http://www.theoi.com/Ouranios/Asklepios.html
6) Epidemiological Characteristics and Trends of Caesarean Delivery in a University Hospital in Northern Greece. Kalogiannidis et al. WAJM 2011; 30(4): 250–254.
7) Health and Social Care Information Centre HSCIC's NHS Maternity Statistics, 2011-12.
8) *Are Operative Delivery Procedures in Greece Socially Conditioned? Skalkidis et al. IntaMhbnalJorvnol for Qucrliry in Hmlth Cur, Vol. 8, NO. 2. pp. 15%165, 1996 http://intqhc.oxfordjournals.org/content/8/2/159.full.pdf * Eur J Public Health (June 2005) 15 (3): 288-295. doi: 10.1093/eurpub/cki002 First published online: May 27, 2005 An investigation of Caesarean sections in three Greek hospitals. The impact of financial incentives and convenience. E. Mossialos et al. http://eurpub.oxfordjournals.org/content/15/3/288.full
9) R Joyce, R Webb, and J L Peacock, “Associations between perinatal interventions and hospital stillbirth rates and neonatal mortality,” Archives of Disease in Childhood. Fetal and Neonatal Edition 89, no. 1 (January 2004): F51-56
10) CIA World Factbook - page is accurate as of July 26, 2012 https://www.cia.gov/library/publications/the-world-factbook/rankorder/22...
11) OECD (2011), “Caesarean sections”, in Health at a Glance 2011: OECD Indicators, OECD Publishing. http://dx.doi.org/10.1787/health_glance-2011-37-en
12) Meagan Zimbeck, Ashna Mohangoo, and Jennifer Zeitlin, “The European perinatal health report: delivering comparable data for examining differences in maternal and infant health,” European Journal of Obstetrics, Gynecology, and Reproductive Biology 146, no. 2 (October 2009): 149-151.
13) New RCOG guidance urges CCGs to increase births without epidurals and reduce caesarean rates to 20%. August 24, 2012, published by electivecesarean.com
14) April 30, 2012 Concerned that flawed analysis may be used to restrict birth choices, Pauline M Hull http://www.bmj.com/content/344/bmj.e2292/rr/581969
15) Preterm birth trends in Greece, 1980- 2008: A rising concern. Baroutis et al. Acta Obstet Gynecol Scand. 2013 Jan 29. doi: 10.1111/aogs.12089. http://www.ncbi.nlm.nih.gov/pubmed/23360152
16) Neonatal Outcomes After Implementation of Guidelines Limiting Elective Delivery Before 39 Weeks of Gestation, Ehrenthal et al. Obstetrics & Gynecology: November 2011 - Volume 118 - Issue 5 - p 1047–1055
Competing interests: Co-author of Choosing Cesarean, A Natural Birth Plan (Prometheus Books 2012) and editor of electivecesarean.com
Gardosi et al(1) reconfirm the need for early antenatal detection to reduce unrecognised fetal growth restriction. Did the authors findings also correlate with those of other studies in which stillbirth risk rises with increasing gestational age?(2) It would be interesting to know specifically, how many stillbirths occurred at 38, 39, 40, 41 and 42+ weeks’ gestation, and whether any respective maternal or fetal risk factors were identified? This information is potentially very important in the context of delivery mode decision-making, particularly when spontaneous labour does not occur. There are essentially three choices: wait for spontaneous labour, schedule induction or schedule a caesarean. An individual’s perception of risk and any delivery preference may influence this decision, and so will any identifiable risk factors. My concern is that women are not being given ALL the information available to help make this decision.
In 2006, U.S. researchers found a significant increase in the stillbirth rate after 39 weeks’ gestation, and estimated that timely delivery could prevent two deaths in every 1000 living fetuses, the equivalent of 6,000 deaths annually. Hankins et al(3) called it “an impact that far exceeds any other strategy implemented for stillbirth reduction thus far.” In 2009, Canadian researchers reported a decrease in life-threatening injuries to babies in a breech cesarean group, despite comparing these with cephalic presenting singletons in ‘healthy, first-time mothers’ (fewer mothers died in the cesarean group too).(4) And in 2010, in a study of nine Asian countries, the neonatal mortality rate was lowest with planned cesareans, as were rates of severe asphyxia and palsy.(5)
Yet in the UK, when stillbirth prevention is discussed, there often seems to be a reluctance to even mention the word ‘caesarean’. For example, in a crucially important stillbirth report last January (submitted for debate in Parliament), the word is notably absent,(6) and in a campaign article last November, a possible euphemism is the closest we get: “Those which happen near the end of pregnancy (about 30%) are potentially the most preventable, if only the baby could be delivered in time.”(7)
Unfortunately, the word ‘caesarean’ has become synonymous with ‘controversial’, and so research and maternity strategies are often framed in the context of a ‘caesarean epidemic’. This is largely due to the 1985 World Health Organization recommendation of a 15% threshold, and despite the WHO’s clarification in 2009 that there is in fact “no empirical evidence” for a caesarean rate threshold in any setting (“an optimum rate is unknown”),(8) the 15% legacy continues to feed an assumption that ‘lowering caesarean rates’ is synonymous with ‘improved health outcomes’ for mothers and babies.
Evidently, planned caesareans are not a panacea for reducing stillbirth rates in all pregnant women with known risk factors, and there are risks besides stillbirth that need to be considered, but they do deserve recognition as a valued element in any overall preventative strategy, and women should be informed of different birth risks and benefits equally.
Just this month, RCOG proposed induction at 39 weeks’ gestation for women aged ≥40 years to reduce the stillbirth risk, but made no reference to planned caesarean. Instead, “improved perinatal outcomes generally without increasing the caesarean section rate” was cited.(9) Also ironically, women who request a caesarean in the UK are frequently advised of the risk of subsequent stillbirth, even though the findings of a 2003 study were later disputed by at least three others.(10)
We are some way from ensuring balance in the information women are given, but it’s important to recognize that this is not just about informed ‘choice’ or birth autonomy. In the context of stillbirth and perinatal mortality, if planned caesareans remain taboo, it can be a matter of life or death.
References
1) Gardosi J, Madurasinghe V, Williams M, Malik A, Francis A. Maternal and fetal risk factors for stillbirth: population based study. BMJ 2013; 346: 1108
2) *Tim A Bruckner, Yvonne W Cheng, and Aaron B Caughey, “Increased neonatal mortality among normal-weight births beyond 41 weeks of gestation in California,” American Journal of Obstetrics and Gynecology 199, no. 4 (October 2008): 421.e1-7 *Yudkin PL, Wood L, Redman CW. Risk of unexplained stillbirth at different gestational ages. Lancet. 1987;1:1192 – 4.*Fretts RC, Elkin EB, Myers ER, Heffner LJ. Should older women have antepartum testing to prevent unexplained stillbirth? Obstet Gynecol. 2004;104:56 – 64. *Nohr EA, Bech BH, Davies MJ, Frydenberg M, Henriksen TB, Olsen J. Prepregnancy obesity and fetal death: a study within the Danish National Birth Cohort. Obstet Gynecol. 2005;106:250 – 9
3) Gary D V Hankins, Shannon M Clark, and Mary B Munn, “Cesarean section on request at 39 weeks: impact on shoulder dystocia, fetal trauma, neonatal encephalopathy, and intrauterine fetal demise,” Seminars in Perinatology 30, no. 5 (October 2006): 276-287.
4) Leanne S Dahlgren et al., “Caesarean section on maternal request: risks and benefits in healthy nulliparous women and their infants,” Journal of Obstetrics and Gynaecology Canada: JOGC = Journal D'obstétrique Et Gynécologie Du Canada: JOGC 31, no. 9 (September 2009): 808-817.
5) Virasakdi Chongsuvivatwong et al., “Maternal and fetal mortality and complications associated with cesarean section deliveries in teaching hospitals in Asia,” The Journal of Obstetrics and Gynaecology Research 36, no. 1 (February 2010): 45-51.
6) January 2012 Preventing Babies’ Deaths what needs to be done, SANDS http://www.appg-maternity.org.uk/resources/Sands+Presentation.pdf
7) November 27, 2012 Stillbirth should be tackled as cot-death syndrome once was, Janet Scott (SANDS), guardian.co.uk http://www.guardian.co.uk/commentisfree/2012/nov/27/stillbirth-needs-to-...
8) Monitoring Emergency Obstetric Care: a handbook. World Health Organization 2009 ISBN 978 92 4 154773 4
9) February 1, 2013 RCOG release: Induction of labour in older mothers may reduce risk of stillbirth, say experts http://www.rcog.org.uk/news/rcog-release-induction-labour-older-mothers-...
10) *Gordon C S Smith, Jill P Pell, and Richard Dobbie, “Caesarean section and risk of unexplained stillbirth in subsequent pregnancy,” Lancet 362, no. 9398 (November 29, 2003): 1779-1784. *S L Wood et al., “The risk of unexplained antepartum stillbirth in second pregnancies following caesarean section in the first pregnancy,” BJOG: An International Journal of Obstetrics and Gynaecology 115, no. 6 (May 2008): 726-731. *R Gray et al., “Caesarean delivery and risk of stillbirth in subsequent pregnancy: a retrospective cohort study in an English population,” BJOG: An International Journal of Obstetrics and Gynaecology 114, no. 3 (March 2007): 264-270. *Mert O Bahtiyar et al., “Prior cesarean delivery is not associated with an increased risk of stillbirth in a subsequent pregnancy: analysis of U.S. perinatal mortality data, 1995-1997,” American Journal of Obstetrics and Gynecology 195, no. 5 (November 2006): 1373-1378
Competing interests: Co-author of Choosing Cesarean, A Natural Birth Plan (Prometheus Books 2012) and editor of electivecesarean.com
To the Editor
We read with great interest the article by J. Gardosi1 and colleagues on maternal and fetal risk factors for stillbirth. The authors analyzed data from 92218 singletons including 389 stillbirths and found (using univariate analysis) a slight increase of stillbirth risk in younger (<25) and older (≥35) mothers (U-shaped risk curve), although this trend did not reach statistical significance. Stillbirth rates did not differ between mothers aged 25-30 and 30-34 (p=0.332) or among age groups <20, 20-24 and ≥35 years (p=0.937). We organized data in two age groups: 25-34 (group A) and <25 or ≥35 (group B), thus a statistically significant higher stillbirth risk of older mothers (≥35), comparing with younger ones (<25) is obtained (RR=1.31, 95%CI: 1.07-1.60, p = 0.008) (table 1).
The association between maternal age and stillbirth risk does not follow a completely clear pattern. Some authors report that risk of stillbirth increases with advanced maternal age2,3, whereas others conclude that an increased risk for stillbirth is associated with both extremes of maternal age4. We analyzed official nationwide birth data from Hellenic statistical authority (EL.STAT)5 (years 2005 and 2006: 220384 total births, including 797 stillbirths). Table 2 shows the stillbirth frequency distribution by maternal age for singletons and multiple births. Relative risks, provided by the odds ratios, for single and multiple pregnancies, form two inverse J-shaped curves (figure 1), although these trends do not reach statistical significance. Curve gradient is higher to the right for singletons (higher risk for older mothers), and to the left for multiple births (higher risk for younger mothers). In a grouped data analysis, in singletons, pregnant women aged ≥35 years have a 53% higher stillbirth risk compared with those younger than 35 years (OR=1.53, 95%CI: 1.28-1.82, p<0.001) and in multiple births, mothers of extreme age (<20 or ≥45) are at 2.8 times higher risk than those aged 20-44 years (OR=2.77, 95%CI: 1.46-5.32, p=0.005).
Finally, we compared stillbirth rates between multiple and single births for each maternal age group and a declining trend in estimated relative risks (odds ratios) is observed: the OR is highest for teenage mothers (<20) and lowest for oldest ones (≥40).
Nikolaos Vlachadis M.D., D.M.D., M.P.H., M.Sc.
Eleni Kornarou Ph.D.
National School of Public Health, Athens, Greece
1Gardosi J, Madurasinghe V, Williams M, Malik A, Francis A. Maternal and fetal risk factors for stillbirth: population based study. BMJ 2013; 346: 1108
2Huang L, Sauve R, Birkett N, Fergusson D, van Walraven C. Maternal age and risk of stillbirth: a systematic review. CMAJ. 2008;178:165-72.
3 Flenady V, Koopmans L, Middleton P, Frøen JF, Smith GC, Gibbons K, Coory M, Gordon A, Ellwood D, McIntyre HD, Fretts R, Ezzati M. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet. 2011;377:1331-40.
4Bateman BT, Simpson LL. Higher rate of stillbirth at the extremes of reproductive age: a large nationwide sample of deliveries in the United States. Am J Obstet Gynecol. 2006;194:840-5.
5www.statistics.gr
Competing interests: No competing interests
Increase of stillbirth rate in Greece
To the Editor
We read with great interest the article by J. Gardosi and colleagues1 on maternal and fetal risk factors for stillbirth and took the opportunity to draw attention to the recent increase in stillbirth rate in Greece.
We analyzed official data of stillbirths in Greece from Hellenic Statistic authority (EL.STAT). Stillbirth rates in Greece have been continuously decreasing during 42 years, from the historic high in 1966 (16.03) to the historic low in 2008 (3.31). The total 4.8 times decline follows an almost perfect exponential model (R2 = 0.9719, average annual rate of change: AARC = –3.8%) (figure 1).
The condition changed dramatically in the latest two years (2009-2010) when stillbirth rate increased by 32% (2010: 4.36) (p<0.0001). Gardosi et al1 conclude that the single largest stillbirth risk factor is fetal growth restriction, especially if not detected antenatally and suggest that the cornerstone of stillbirth prevention is an adequate antenatal care for early detection of fetal growth restriction and other obstetric complications. The dramatic increase of stillbirth rate is probably associated with the Greek economic crisis which started in 20092. We are concerned that stillbirth rate will further rise in Greece in the following years, since an increasing number of pregnant women are unemployed and without insurance, excluded from Hellenic national health system’s obstetric care.
Nikolaos Vlachadis M.D., D.M.D., M.P.H., M.Sc.
Eleni Kornarou Ph.D.
National School of Public Health, Athens, Greece
1 Gardosi J, Madurasinghe V, Williams M, Malik A, Francis A. Maternal and fetal risk factors for stillbirth: population based study. BMJ 2013; 346: 1108
2Timeline-Greece's economic crisis.
http://www.reuters.com/article/2009/12/22/greece-economy-events-idUSLDE5... (accessed Feb 2, 2013).
Competing interests: No competing interests
Re: Maternal and fetal risk factors for stillbirth: population based study
The authors have primarily discussed antepartum stillbirths. Early detection of fetal growth restriction will decrease a chunk of the risk of antepartum stillbirths, according to the authors. The authors have also found out that Pre-eclampsia and abruptio placenta but not gestational diabetes increased the risk of stillbirths.
This is a bit confusing as we all know that early detection of risk factors and their management will reduce the risk of stillbirths from happening. Abruptio placenta clearly may reach a stage of not returning to normal. Gestational diabetes and pre-eclampsia (PET) can both be treated too. From these data it appears that antenatal management of PET is not so effective and more research is needed for effective therapy.
Competing interests: No competing interests