Stillbirth, the birth of a baby without signs of life after 20 weeks’ gestation, is a tragedy for parents and families and a major unaddressed public health problem.
Stillbirth has enormous psychosocial impact on parents and care providers, and wide-ranging economic impact on health systems and society at large (Heazell 2016). In The Lancet 2016 Ending Preventable Stillbirths series we emphasise that the poor global response to stillbirth has been a persistent injustice to families and communities.
As stated by Richard Horton, Editor in Chief of The Lancet: “Not all global health issues are truly global, but the neglected epidemic of stillbirths is one such urgent concern.”
What is stillbirth?
- In Australia, stillbirth is defined as the birth of a baby without signs of life after 20 weeks’ gestation or 400g birthweight.
- In many other countries, they count babies as stillborn after 28 weeks (or the ‘third trimester’ of pregnancy), so comparing Australia with overseas is often difficult.
How frequent is stillbirth?
- The stillbirth rate in Australia is currently 6.8 per 1000 births (AIHW 2019).
- Each day in Australia, 6 babies are stillborn, affecting almost 2,200 families each year (AIHW 2019).
- Australia’s current late-gestation (>28 weeks) stillbirth rate is 2.2 per 1000 births (Flenady et al 2020).
- The risk of stillbirth is higher for Aboriginal and Torres Strait Islander women (AIHW 2020), South Asian and African women (Davies-Tuck, Davey & Wallace 2017; Mozooni, Preen & Pennell 2018), as well as women from disadvantaged groups (Flenady 2016 & AIHW 2020).
How does stillbirth affect parents and families?
- The death of a baby is a highly distressing event for parents and families. Grief is a normal response and high levels of distress are a normal part of the grieving process.
- Respectful and supportive care that incorporates good communication, recognition of parenthood, shared decision-making and effective support is important for the immediate and longer-term wellbeing of parents and families (Boyle et al 2020).
- Clinical practice guidelines are available to assist health care professionals and maternity services provide care that meets the needs of parents following the death of a baby (Flenady et al 2020).
- The psychosocial consequences of stillbirth are wide ranging and effective support is critical to reduce the adverse impacts. Parents who have had a stillborn baby face an increased risk of anxiety, depression, post-traumatic stress, and suicidal ideation as well as relationship problems, employment difficulties and economic hardship (Heazell et al 2016).
- Stigma around stillbirth intensifies parents’ distress and often makes them feel more isolated in their grief. Our research has shown that many bereaved parents feel unable to talk about their stillborn baby because it makes people feel uncomfortable and that the magnitude of their loss is not well understood (Flenady et al 2016).
Are stillbirth rates improving?
- There has been little improvement in overall stillbirth rates for over 30 years (Flenady et al 2020).
- Some encouraging trends toward reductions are evident in rates after 28 weeks’ gestation. From 2010-2016, the 28-36 weeks rate reduced by 20% from 1.71 to 1.39/1000 (ongoing pregnancies) and for 37 weeks or more by 30% from 1.43 to 1.02/1000. However, there has been no change between 24 and 27-weeks’ gestation, and the rate of extremely early gestation stillbirths (20 to 23 weeks) has increased (Flenady et al 2020).
- The 2020 United Nations Inter-Agency report on global estimates for stillbirth rates showed a 31% decline in stillbirth after 28 weeks’ gestation in Australia between 2000 to 2019. However, improvements have not kept pace with other high-income countries like Japan (40.2%), Denmark (35.9%), Sweden (34.4%) and Singapore (33.1%), which recorded greater improvements.
What are the causes of stillbirth?
- The major causes of stillbirth greater than 28 weeks’ gestation in Australia are: fetal growth restriction (11.7%), antepartum haemorrhage (9.5%) and congenital abnormality (9%).
- 39.9% of stillbirths that occur after 28 weeks’ gestation in Australia are unexplained.
- The major causes of stillbirth less than 28 weeks’ gestation in Australia are: congenital abnormality (31.3%), maternal conditions (18.2%) and spontaneous pre-term birth (16.1%), while 11.1% of deaths remain unexplained.
- Many stillbirths are not adequately investigated, resulting in possible missed diagnoses.
- Autopsy and placental pathology are the most important investigations to understand why the baby died.
- Even when all investigations have been undertaken some stillbirths remain unexplained and more research is needed to understand why this occurs.
- In 20-30% of stillbirths, the quality of maternity care provided is a contributing factor to the death (Flenady et al 2011). It is hoped that the Safer Baby Bundle, which is being implemented around Australia, will reduce the numbers of these deaths through improving pregnancy care.
- It is important that every baby who is stillborn is fully investigated to identify the causes and contributing factors so parents have all the information to understand why their baby died and to help with future prevention for all families.
- The Stillbirth CRE is undertaking research to reduce the numbers of stillborn babies and to improve care for families who experience stillbirth.
What are the risk factors for stillbirth?
- Risk factors include maternal perception of decreased fetal movements (strength or frequency), fetal growth restriction, smoking, hypertension, diabetes, overweight and obesity, pregnancy beyond 41 weeks’ gestation, primiparity, maternal age over 35 years (particularly for women aged 40 years or more), and previous stillbirth (Flenady 2011).
- Smoking in pregnancy is one of the major contributors to stillbirth. Every puff of a cigarette has an immediate negative effect on the baby. Smoking cessation support helps women to stop smoking and is available during antenatal care.
- Fetal growth restriction - Risk assessment for fetal growth restriction should be undertaken in early pregnancy and at each antenatal visit through inquiry about maternal characteristics and medical history, previous obstetric history and risk factors that may arise in pregnancy.
- Decreased fetal movements - Getting to know the pattern of your baby’s movements is important—it is a way your baby can tell you that they are well. There is no set number of normal movements. You should get to know your baby’s movements and what is normal for them.
- Sleep on side from 28 weeks - Research shows that side sleeping on either side from 28 weeks of pregnancy can halve the risk of stillbirth compared to going to sleep on your back.
- Timing of birth for women with risk factors - If there are health concerns that might increase the risk of stillbirth, your health care professional will discuss with you how the timing of birth might reduce your risks, with your pregnancy continuing as long as it is safe for you and your baby.
All women should be assessed early in pregnancy for the presence of risk factors and subsequent care should be planned accordingly.
For information about our Research Program and how we are addressing the problem of stillbirth, see our research program.
References:
Australian Institute of Health and Welfare (AIHW). Stillbirths and neonatal deaths in Australia 2015 and 2016: in brief. Perinatal statistics series no. 36. Cat. no. PER 102. Canberra: AIHW, 2019.
Australian Institute of Health and Welfare (AIHW). Australia’s mothers and babies 2018: in brief. Perinatal statistics series no. 36. Cat. no. PER 108. Canberra: AIHW, 2020.
Boyle F, Horey D, Dean JH, Loughnan S, Ludski K, Mead J, et al. Stillbirth in Australia 5: Making respectful care after stillbirth a reality: The quest for parent-centred care. Women and Birth. 2020 (33), 531-536.
Davies-Tuck ML, Davey MA, Wallace EM. Maternal region of birth and stillbirth in Victoria, Australia 2000-2011: A retrospective cohort study of Victorian perinatal data. PloS one. 2017;12(6): e0178727.
Flenady V, Middleton P, Smith GC, Duke W, Erwich JJ, Khong TY, et al. Stillbirths: the way forward in high-income countries. The Lancet. 2011;377(9778):1703-17.
Flenady V, Wojcieszek AM, Middleton P, Ellwood D, Erwich JJ, Coory M, et al, for the Lancet Ending Preventable Stillbirths series study group. Stillbirths: recall to action in high-income countries. The Lancet. 2016;387(10019):691-702.
Flenady V, Middleton P, Wallace E, Morris J, Gordon A, Boyle F, et al. The road to now: two decades of stillbirth research and advocacy in Australia. Women and Birth. 2020 (33), 506-513.
Flenady V, Oats J, Gardener G, Masson V, McCowan L, Kent A, et al, for the PSANZ Care around the time of stillbirth and neonatal death guidelines group. Clinical Practice Guideline for Care Around Stillbirth and Neonatal Death. Version 3.4, NHMRC Centre of Research Excellence in Stillbirth. Brisbane, Australia, January 2020.
Heazell AE, Siassakos D, Blencowe H, Burden C, Bhutta Z, Cacciatore, J, et al. Stillbirths: economic and psychosocial consequences. Lancet (London, England). 2016 Feb;387(10018):604-616.
Mozooni, M, Preen, D B, Pennell C. Stillbirth in Western Australia, 2005–2013: the influence of maternal migration and ethnic origin. Med J Aust 2018; 209 (9): 394-400. || doi: 10.5694/mja18.00362 Published online: 8 October 2018
United Nations Inter-agency Group for Child Mortality Estimation (UN IGME), ‘A Neglected Tragedy: The global burden of stillbirths’, United Nations Children’s Fund, New York, 2020.
"The death of an unborn child has enormous psychosocial impact on parents and care providers, and wide-ranging economic impact on health systems and society at large."
