Giving birth to a still, silent child is surely one of the greatest tragedies to befall a woman, causing unimaginable grief and pain. For far too long such losses have gone uncounted and largely unnoticed by the Global Health Community. There was no mention at all of stillbirth in the Millennium Development Goals, despite the presence of bold targets aimed to draw attention and action to the parallel travesties of avoidable child and maternal deaths.
The Lancet series on Stillbirth in 2011, attempting to bring stillbirth to international notice, exposed significant disparities between the global stillbirth burden and the relative absence of attention to the problem on the agenda even of the maternal and child health communities, let alone the global health community as a whole. The response to this first series notwithstanding, no systematic monitoring of progress occurred and there are no specific targets relating to stillbirth in the Sustainable Development Goals, this despite an estimated 2.6 million children who are stillborn annually. If stillbirth was included in the world listings of causes of death it would rank 5th, ahead of lung cancer, HIV, Diabetes and Road Traffic Injury, each of which cause an approximate 1.5 million deaths annually.
It is no surprise that 98% of stillbirths occur in the low and middle income countries that bear a similarly disproportionate burden of maternal and child death. In common with these deaths, most stillbirths are preventable. Overall, about half of all stillbirths occur during the intra-partum period, although this proportion differs widely between and within countries. A significantly greater proportion of losses relate to intra-partum events in LMICs.
In terms of absolute numbers, India tops the table with approximately 600,000 stillbirths annually, but Pakistan and Nigeria have the highest rates, at 43.1 and 42.9/1000 births respectively, both more than twice the global average of 18.4/1000 births in 2013. By comparison the best rates are to be found in Iceland, at 1.3/1000 births. At the current average annual rate of reduction, it is estimated that the stillbirth rate in Sub-Saharan Africa will reach Icelandic levels by 2124.
Despite the disappointing lack of a mention in the SDGs, the global health community has not entirely ignored the issue, and in 2014 the World Health Assembly endorsed the Every Newborn Action Plan which does incorporate specific targets for stillbirth, with interim goals on the way to a global target level of 10/1000 to be achieved by all countries by 2035. Stillbirth now features on the WHO’s list of core health indicators.
The new Lancet series, Ending Preventable Stillbirths, published in January 2016 is a welcome further development. It aimed to assess progress to date and highlight the necessity of completing the long journey ahead to achieving the targets. In doing so, it rightly highlighted the priority needs for improved registration and metrics. Without measurements, stillbirths are literally not counted and neither are improvements or deteriorations in rates. It is clear that what is not counted does not count, otherwise the place that stillbirth would have rightfully occupied on the world disease ranking would surely have provoked a global response. Beyond appropriate metrics, stillbirth prevention needs to become an integral part of the continuum of care advocated as policy for women and children’s health and monitored by Countdown.
It has been well established that syphilis is a cause of pregnancy loss and stillbirth, and it is estimated that detection and treatment of this disease might prevent up to 7.7% of all stillbirths. And yet, large gaps in coverage for antenatal syphilis diagnosis and treatment remain, even though effective treatment is both available and cheap. All women who are infected with syphilis require treatment for the benefit of their own health, not just that of the baby they are carrying. Failure to provide universal diagnostic and therapeutic services in the end boils down to a lack of appropriate prioritisation on the part of health care agents and their funders.
If countries can’t get even the relatively simple matter of syphilis treatment right, it suggests that there is a lot less hope for the provision of quality intra-partum care, with appropriate fetal monitoring leading to the detection of fetal distress and available timely caesarean section or assisted vaginal delivery. Approximately 1.3 million stillbirths occur in labour. Whilst many cases occur as a consequence of an acute sentinel event such as, for example, uterine rupture or maternal eclampsia, others have a less dramatic causation, perhaps an umbilical cord caught around the baby’s neck, cutting off vital oxygen supplies.
To avoid the often inevitable consequences of letting nature take its course in this circumstance, a midwife must be available to give one to one care in established labour, in particular in the second stage, and she must be suitably trained to provide appropriate fetal monitoring and to recognise abnormalities in that process and to either perform an assisted vaginal delivery herself or have urgent recourse to a doctor who can do both that or a caesarean section. To enable this, there must be available functioning equipment and an operating theatre which is staffed, clean and ready to receive a case 24 hours a day. In reality many health systems around the world do not provide anything like universal access to this level of functionality. And stillbirths represent the tip of a large iceberg of the longer-term consequences of birth asphyxia, which cripples many children and their families worldwide.
Capacity planning and funding functional, effective maternity care is a great deal more difficult and costly than providing treatment for syphilis, but yet providing for both of these measures, and others beside, are what it will take to accelerate the reduction in the global burden of stillbirth. It has rightly been pointed out that the stillbirth rate is a sensitive marker of both quality and equity in health care provision. It is to be hoped that this latest Lancet series will serve as a prompt to push leaders of health system further along the way to both appreciating the devastating consequences of the birth of a silent baby and doing what it takes to prevent families experiencing this all too often avoidable grief.
Featured image: Pregnancy serie © Roberto Carlos Pecin
Dr Helen Allott has been an NHS consultant in obstetrics since 1994, and in 1999 became the founding chairperson of Kisiizi Partners, a UK based charity supporting Kisiizi Hospital to deliver rural health care. She has delivered many obstetric training interventions in Sub-Saharan African countries and beyond, and is Clinical Lead for the RCOG’s Excellence in Obstetric Skills project in Uganda and a part-time honorary lecturer at UCL.