Stillbirth-A Silent Cry For More Attention

The voice of the stillborn is too silent to be heard. Stillbirth is defined by World Health Organization (WHO) as a baby born with no signs of life at or after 28 weeks of gestation. Stillbirth is one of the most important but most badly understood and severe outcome of pregnancy. For years 2.6 million stillbirths have been documented worldwide, and more than 7,178 deaths are recorded per day with majority of the deaths occurring in developing countries as well as low-and middle-income countries. Stillbirth is usually termed as a “hidden problem” that seems to take the lives of many unborn children and as a matter of fact not much work is being done to address this situation. Socioeconomic, social demographic, obstetrics, maternal medical conditions, and behavioral factors are mostly used to classify the determinants of stillbirth.

In every year, over two million babies die before they are born and it is estimated that, there are 18.9 stillbirths per 1000 births worldwide with more than 7,178 deaths per day. Developing countries have the highest amongst all other countries and they have the most occurrence of stillbirth with a percentage of 98%. In the intrapartum period, about half of all stillbirths occur representing the greatest time of risk. The rate of stillbirth for developed countries is estimated between 4.2 and 6.8 per 1000 births, whereas for the developing countries, the estimate ranges from 20 to 32 per 1000 births. The etiological factors for stillbirth are also different in developed and developing countries. The rate of stillbirth during labor is 1 in 1000 in developed countries, whiles in developing countries it is 1 per 100 births. Most of the times, almost all stillbirths and neonatal deaths are not reported. Like in many countries in Sub Sahara Africa, stillbirths are not routinely and adequately recorded and monitored.. The underreporting of neonatal death and stillbirth is sometimes not considered in the global health agenda. Underreporting usually occurs for a number of reasons which involve the practice of isolating women and their newly born babies in the early postnatal period, accepting the death of the newborns as a normal situation and having a perception that newly born babies are not individuals at a particular period of time.

Moreover, the factors that determine stillbirth overlap hugely with those of maternal and neonatal deaths. The risk factors for maternal deaths which are hypertension, hemorrhage, anemia, malaria and other maternal infections are also risk factors for both antepartum stillbirths (stillbirths that occur before the onset of labor, usually more than 12 hours prior to delivery; also called macerated stillbirths) and intrapartum stillbirths (stillbirths that occur after the onset of labor, usually less than 12 hours prior to delivery; also called fresh stillbirths). One of the major causes of intrapartum stillbirths is prolonged or obstructed labor. Foetal causes of stillbirth like congenital malformations, foetal growth restriction, prematurity, and foetal asphyxia are all related to maternal risk factors, although the cause of stillbirths may be unknown in up to about one-third of cases. Antepartum stillbirths reflect quality of antenatal care, while intrapartum stillbirths reflect quality of delivery care. The objective of this study is to assess the determinants of stillbirths. The causes of stillbirths are grouped into socioeconomic, social demographic, obstetrics factors, and maternal medical conditions.

Socioeconomic factors are known to also contribute to the causes of stillbirth. Educational level of women is one of the important factors in determining the cause of stillbirth. Low level of education is a common risk factor for stillbirth. Countries which have very few women having primary or secondary level of education or women with less than seven years of schooling have a higher probability of having stillbirth than that of the other countries which have more of its women having tertiary education. The reason behind this is that the probability that the more educated women will take their antenatal visits very keenly is higher than the less educated women since they might have had no or a little knowledge about the regular visits to the clinic when pregnant. Mostly less educated women go to the hospitals when they encounter severe complications which cannot be handled at home. In addition, the consumption of unsafe water and the use of biomass fuels shows how low educational level is associated with stillbirth, this can examine stillbirth burden in countries like Ghana attributable to socioeconomic disadvantage. The occupation of women is also a factor that can determine the rate of stillbirth. For example, extreme heat, smoke and disinfectants at work can lead to complications that can cause stillbirth. Home use of pesticide (pesticides for control of ants, cockroaches, etc.) is also one of the potential risk factors of stillbirth during pregnancy.

Social demographic factors that contribute to the causes of stillbirths include the sex of foetus, age of the mother and the place of residence. An analysis, which includes data on more than 30 million births, relate sex to stillbirth, the risk being about 10% higher in male foetuses than in female foetuses. In the analysis, it was estimated that about 4% of stillbirths in the whole population are sex-associated and among male foetuses. Globally, this proportion is equal to approximately 100,000 stillbirths per year. Across different populations and income groups, there has been a highly consistent pattern of excess male foetus mortality. This is so because there are differences in male and female development which begin very early in life. For example, the chromosome Y genes are transcribed at the two-cell stage and, in animal models, male embryos have faster development and higher metabolic rates than females, potentially leaving the male foetus more vulnerable to a range of stressors and anomalies, including endocrine fluctuations, oxidative stress, and nutritional compromise. An experimental work done recently in animal models has demonstrated that gene expression in the murine placenta is adaptive and shaped by diet, with placental growth in males being more susceptible to nutritional compromise than that of females. It is known that risks of preterm delivery are greater in male infants than female infants and sex-specific differences in placental structure and function among pregnancies complicated by preterm delivery have been demonstrated.

The age of mothers also have a link in stillbirth. Different risk factors may defer and operate at different maternal ages. A larger percentage of births in Africa are to women < 20 years of age. Mothers at the age of 24 have a higher risk of stillbirth compared to mothers between the ages of 25-34years. Extremes of age have been considered as a risk factor for both antepartum and intrapartum stillbirth. As women age there are changes in hormonal balance and when these women get pregnant, they are predispose to certain congenital anomalies, disease conditions and mutations in genes that can lead to stillbirth. Stillbirth is significantly associated with the place women reside. Women who reside in the rural areas has a higher risk than those in the urban areas. The reason being that the rural areas lack skilled and experienced attendant at delivery and may lack important information about delivery.

The primary obstetric causes of stillbirth include antepartum haemorrhage, parity, hypertensive disorders etc. Parity which means the number of birth is found to be significantly associated with stillbirth as such both primiparous and multiparous women are potentially at an increased risk for stillbirth. Antepartum haemorrhages (APH) including abruption and placenta previa are responsible for 30% of stillbirths. In a large WHO trial, involving seven developing countries, hypertensive disorders of pregnancy were responsible for 28% of stillbirths, following prematurity as the most common cause of stillbirth. Hypertensive disorders during pregnancy and preterm labour, increase the chances of stillbirth.

Some causes of stillbirth include, infections, obstructed labour, cord accidents, and foetal abnormalities. Furthermore, the other determinants which increase the risk of a stillbirth are pregnancy complications, multiple gestations, and a past stillbirth which are well known risk factors. It is not clear that what may be responsible for the relation between having a sister who died from pregnancy complications and having a stillbirth. Some people present possible reasons that consist of the familial component of some risk factors for both maternal deaths and stillbirths, like hypertension and diabetes. It may also be as a result of poor access to good quality health care by women with sisters who may have been affected by similar contextual factors. Moreover, the risk of stillbirth is higher in twins than that of a single baby.

Maternal medical factors which includes malaria, anaemia, body mass index (BMI), blood pressure, diabetes, protein in urine, syphilis infections, weight, hypertension and hemorrhage can lead to antepartum or intrapartum stillbirth. Body weight, hypertension and blood pressure are significantly associated with stillbirth. These conditions contribute hugely in determining stillbirth because the developing foetus takes its nutrients from the mother through the placenta. When diastolic blood pressure is less than 80mmHg, especially in late pregnancies, it is usually associated with stillbirth.

The response to delivery of a stillbirth is dependent on the cultural belief and practices of the affected family. Stillbirth is one subject that is hardly discussed openly at home or within the health sector. In the home, the affected mother is encouraged to grieve for short period and at the hospital level, the health worker encourages the mother to get herself together as quickly as possible and plan for next pregnancy. In my opinion, one of the ways to facilitate discussion around stillbirth openly and more often is to place it on a national agenda. Getting stillbirth on the national agenda is not seen as pushing away other important issues; however, it is a way of saying that there is need to give stillborns the same attention that is given to babies born live and high quality respectful care to women and babies( whether live or stillborn). In this regard, women whose pregnancies end as stillborn should receive post loss care, which is virtually nonexistent. This is the time to act. Paediatricians, policy makers, development partners, midwives and nurses should help in mass education. Although there is an improvement in the attention given to stillbirths, more needs to be done to involve affected families and provide post loss care for the mothers and their families.

acknowledgment
Dr. kingsley Preko
Dr. A.T Derrick
Ps. Owusu Badu(End time Assemblies of God)
Ps. Ransford Obeng
written by
Tenga, Dezermy Richard.
Physician Assistant Student.
Level 200
University of Cape Coast.