Lucy Selman: Reducing preventable stillbirth rates in the UK

More must be done—Nine babies every day is just too many

The low, featureless hum as the midwife moved the Doppler foetal monitor across my belly is a sound I wouldn’t wish on anyone. Heavy with meaning, it hung in the room, dragging my husband and me into an unimagined future. Our daughter, Ada, had died. The next morning I would be induced, and at 13:52 I’d give birth to her.

Three months later, we met our consultant to discuss Ada’s post-mortem and the results of the myriad blood tests and swabs taken from me before and after she died. My waters had broken at 26 weeks, 4 days. She died six days later. The cause of death was pneumonitis, and there were signs of bacterial infection in the placenta. Ada’s skin showed traces of streptococcus (though not group B, which is a major cause of stillbirth). It was not certain whether Ada’s infection occurred before or after the foetal membranes ruptured, but infection markers in my blood were elevated when I arrived at the hospital with my waters broken, and the consultant’s best guess was that a sub-clinical infection caused the membranes to rupture. Two months earlier I had had an asymptomatic urinary tract infection and been given antibiotics. A couple of weeks later I felt mild UTI symptoms, but a dipstick test was negative. I had no other obvious symptoms—no cough, cold, flu or nausea.

In the UK, 1 in every 225 births is a stillbirth—a baby born dead after 24 completed weeks of pregnancy. That’s around 3,400 babies dying every year, or 9 every day, on average. 23 high-income countries have lower stillbirth rates than the UK. In high-income countries, substandard care contributes to 20–30% of all stillbirths. The charities SANDS and Tommy’s work to improve these figures, and the experiences of bereaved parents. But clinical action, government investment and further research is needed. Here are six ways we can reduce stillbirths in the UK.

  • Identify and treat urinary tract infections. UTIs, including asymptomatic bacteriuria, are common, affecting 8% of pregnant women, and have known risks. Screening in early pregnancy via the gold standard of cultured urine tests is routine, enabling prescription of antibiotics when indicated. But follow-up is required: a urine culture should also be performed seven days after completion of antibiotic treatment as a test of cure. In cases in which a pregnant woman presents with UTI symptoms, or has had a previous infection during the pregnancy, dipstick (reagent strip) tests should not be relied upon due to their insufficient sensitivity. An algorithm and a phone app summarising the management of suspected lower UTIs in pregnant women are available through the Scottish Intercollegiate Guidelines Network.
  • Monitor stillbirth rates. The UK conducts national audits on perinatal mortality. While these show that over the past 4 years the rate has started to decrease, there was no improvement from 2015 to 2016, and substandard antepartum and intrapartum care is too often present when a stillbirth occurs. For example, improvements in care which may have made a difference to the outcome have been identified in 60-80% of babies who die at term, either shortly before or during birth. In England, the Saving Babies’ Lives Stillbirth Care Bundle was launched in 2016 as a response to audit findings. This is a step in the right direction, though its effectiveness is not yet known.
  • Investigate stillbirths. All stillbirths deserve high-quality investigation. In three-quarters of cases, detailed evaluation enables identification of probable or possible causes of death, compared with only about half when medical records alone are investigated. Bereaved parents should have access to a post-mortem and placental histopathology, and the opportunity to discuss the death with their consultant in a timely, compassionate manner. The quality of local reviews is variable and many would benefit from improvement. The national Perinatal Mortality Review Tool (PMRT) launched this year aims to support high-quality, multidisciplinary local review of the care provided at all stages of the maternity and neonatal pathway. Again, its effectiveness and acceptability to parents is not yet known.
  • Conduct research. About half of all stillbirths are linked to complications with the placenta, and key research focuses on understanding placental pathways to stillbirth. Ascending bacterial infection prior to membrane rupture is the most important infectious cause of stillbirths—and the most probable cause of Ada’s death. Developing a better understanding of this complication and how to reduce its occurrence is vital. Other important areas for research have been identified by the Stillbirth Priority Setting Partnership.
  • Address stigma and fatalism. In high-income countries, about half of parents who have suffered a stillbirth feel they should not talk about their stillborn baby because it makes others feel uncomfortable, and two-thirds of parents feel that the people around them believe most stillbirths are unavoidable. My personal interest in information about cause of death was interpreted by some people as a desire for control over a sad but inevitable situation, rather than a normal reaction to my child’s death. Social perceptions and actions that dismiss the importance of a stillborn child or parental grief, or support the idea that a child was never “supposed” to live, not only harm bereaved parents, but also undermine efforts to reduce stillbirth rates.

Not all stillbirths are preventable, and we don’t know with certainty that Ada’s was. What is certain is that more must be done in the UK to reduce stillbirths—and the family devastation they bring—by ensuring excellence in the care of women during pregnancy and labour. Nine babies every day is just too many.

Lucy Selman is a senior research fellow in Population Health Sciences, Bristol Medical School, University of Bristol.

Conflicting interests: None declared.

Twitter: @Lucy_Selman