Lancet Stillbirth Series Papers

Lancet Stillbirth Series

The Lancet started a stillbirth series of papers in 2011.  The 2011 call to action was created to review the status of stillbirth and evidence of cost effective interventions.  They released another set of research papers in January 2016.  We are very grateful to The Lancet for the wonderful research they have done pertaining to the subject of stillbirth.  The papers are very thorough. It certainly appears an enormous amount of research has been completed, and they have great suggestions backed by research to reduce the stillbirth rate worldwide.

 

Below are my notes on the papers.  After reading the papers I decided to create a quick list of some of the points in the papers.  I encourage you to read the papers in their entirety as these are just my notes pertaining to Stillborn Speak's mission.

 

Ending Preventable Stillbirths 1

Stillbirths: Progress and Unfinished Business

 

  • Stigma and taboo.  The negative stigma and taboo associated with stillbirth needs to be addressed publicly in order to bring more light to stillbirth as a problem.  We need to humanize these babies.  They are not just stillbirths.  They are babies that have been conceived and have died while growing in the womb
  • Dissimilar definitions are a problem.  Countries, and even states within countries, use different definitions.  Data comparisons are inconsistent and present problems for researching stillbirth
  • Better leadership is needed in public domain.  There are not enough political and civil actors bringing attention to stillbirth
  • Better and stronger parental groups are needed to push stillbirth issue into public awareness

 

Ending Preventable Stillbirths 2

Stillbirths: Rates, Risk Factors, and acceleration towards 2030

 

  • Prolonged pregnancies contribute to 14% of stillbirths
  • Congenital abnormalities account for only 7.4% of all stillbirths
  • International Classifications of Diseases (ICD) definitions of stillbirth:
    • Birth weight is given priority over gestational age
    • Late fetal death 1000g or 28 weeks or more or 35cm or more
    • Early fetal death 500g or 22 weeks or more or 25cm or more
  • WHO definition of stillbirth:
    • For international comparison WHO uses 1000g or more with an assumed equivalent of 28 weeks or more
  • USA example using these differing definitions:
    • Using the ICD 500g or more definition, the stillbirth rate is reduced by 40% when compared to the definition of 22 weeks
    • Using the ICD 1000g or more definition, the stillbirth rate is reduced by 21% when compared to the definition 28 weeks
    • This example shows the importance of using only one parameter when specifying stillbirth
  • The Lancet suggests using the gestation age in weeks as the stillbirth definition determinant
  • Male babies have a 10% higher risk of stillbirth
  • Smallest babies in terms of age and weight are at highest risk
  • 6.7% of stillbirths are attributable to advanced maternal age (greater than 35 years old)
  • Short interpregnancy interval is another important risk
  • Diabetes, obesity, and hypertension affect pregnancies in all regions, especially when coupled with advanced maternal age.  The Lancet estimates about 10% of stillbirths are attributable to these risks
  • Greater than 42 weeks gestation accounts for 14% of stillbirths
  • Data improvements and information systems are needed

 

Ending Preventable Stillbirths 3

Stillbirths: Economic and Psychosocial consequences

 

  • Data for direct costs of stillbirth is sparse but suggests more resources are needed for a stillbirth than a live birth
  • Costs associated with stillbirth is largely unknown due to health metrics neglecting stillbirth
  • Direct stillbirth costs, medical bills, were typically met by government or insurance companies
  • Indirect stillbirth costs, funeral and burial, for some this cost was mitigated by health insurance companies, government, or grants.  Parental responses in a survey completed by the International Stillbirth Alliance show a substantial financial burden in this indirect costs category
  • Return to work policies are needed for family members who have faced a stillbirth event.  International Labour Organization database shows only 12 of 170 countries with maternal policies have a specific provision for stillbirth
  • Families were cited as the most frequent source of support.  Relationships are strained during this time of support
  • Most frequently reported experiences after stillbirth are negative psychological symptoms, including high ratio of depressive symptoms, anxiety, post-traumatic stress, suicidal thoughts, panic, and phobias
  • In high income countries 60-70% of grieving mothers reported grief related depression symptoms they regarded as clinically significant 1 year after the baby’s death.  These symptoms occurred for at least 4 years after the loss in half of the cases
  • Psychological distress persisted in subsequent pregnancies.  Women tend to report volatile emotional states and fathers tend to report suppressing their feelings
  • Professionals (doctors and staff that assist with the stillbirth process) also have psychological effects, professional effects, and need support.  Psychological effects include: trauma, diminished emotional availability, stress, and affective states such as guilt, anger, blame, anxiety, and sadness.  The professional effects are fear of litigation and disciplinary action
  • 43 studies provided evidence of what works to reduce the negative effects of stillbirth:
    • Families seeing and holding the baby
    • Social support and support groups
    • Families making and sharing memories
    • Autopsy
    • Psychological interventions
  • Fathers and siblings need to be acknowledged and included in interventions to mitigate their experiences of the negative effects of stillbirth

 

Ending Preventable Stillbirths 4

Stillbirths: Recall to Action in High-Income Countries

 

  • Substandard care contributes to 20-30% of all stillbirths and even higher for late gestation stillbirths that occur during delivery
  • Need to reduce stigma and improve bereavement care
  • In high income countries women living in adverse socioeconomic conditions are at twice the risk of having a stillbirth
  • According to an International Stillbirth Alliance survey:
    • 2 in 3 respondents felt their community believed stillbirths are not preventable
    • 1 in 2 parents felt their community believed parents should not talk about their stillborn baby because it makes people feel uncomfortable
  • Crucially important to have normal bodyweight at onset of pregnancy
  • Resources continued to be diverted away from perinatal pathology services despite stillbirths and neonatal deaths outnumber all deaths from cancer
  • Only 26% of autopsies were undertaken by or supervised by perinatal or pediatric pathologists
  • Only 33% of reported autopsies were routinely completed after consent
  • Classification of cause of stillbirth needs to be standardized
  • Disadvantaged women are less likely to receive adequate care while pregnant
  • Social determinants that are risks:
    • Poverty
    • Experiences of discrimination
    • Incarceration
    • Addiction
    • Chronic stress
    • Inadequate education
    • Child care
    • Employment
    • Transportation
    • Living conditions
    • Intimate partner violence
    • Cumulative effects of stressful life events
  • All high-income countries must monitor and report socioeconomic status in vital statistics
  • Need high efforts to engage populations at risk, including outreach strategies and transportation to health services
  • Low dose aspirin and heparin have been used to improve placental function and decrease stillbirth
  • Preconception care is a potentially valuable intervention yet only 28% of care providers said preconception care was implemented
  • More than a third of parents believed their concerns were not taken seriously or felt not listened to, either before or after their baby was stillborn
  • In survey of care providers, 23% reported being satisfied with training opportunities in bereavement care and 30% reported no opportunities for training
  • Stillbirth prevention needs quality maternity care.  Quality can be improved through better communication and information
  • Quality bereavement care must be emphasized with greater access to training being a crucial first step
  • Audit and feedback benchmarking programs with explicit targets are effective
  • Substandard care factors are present in high proportion of cases
  • Before 39 weeks, early delivery needs to balance any reduction in stillbirth risk against morbidity and long term mortality of offspring and should be only considered in the presence of a substantial risk for maternal or neonatal complications
  • Universal ultrasound is effective in the identification of fetal growth restriction
  • Raising awareness of decreased fetal movements might aid stillbirth prevention through timely detection and reporting, but concerns exist about potential to increase anxiety
  • Adverse effects of supine sleep position (on your back) in late pregnancy has been emphasized as a potentially modifiable risk factor for stillbirth

 

Ending Preventable Stillbirths 5

Stillbirths: Ending Preventable Deaths by 2030

 

  • 2.6 million 3rd trimester stillbirths worldwide
  • 5 priority actions to change stillbirth trend
    • Internal leadership
    • Increased voice, especially from women
    • Implementation of integrated interventions with commensurate investment
    • Indicators to measure effect of interventions and especially monitor progress
    • Investigate critical knowledge gaps
  • Half of worldwide stillbirths occur during delivery.  These deaths are highly preventable with high quality care
  • Use of term stillbirth is infrequent in reporting research and funding
  • 3 ways to incorporate stillbirths into post-2015 initiatives
    • Acknowledge burden of stillbirth
    • Address actions needed to prevent stillbirths
    • Monitor stillbirths with a target or outcome indicator
  • Need strong network of connections amongst stillbirth organizations

 

 

 

 

 

Stillborn Speak | cearles@stillbornspeak.org