Updated 6/2024
Stillbirth is still a problem despite advances in obstetrical care
Thanks to early diagnostics, advancements in screening and testing, and increasing knowledge by both physicians and patients, we are now able to deliver more healthy babies than in the past. However, even as modern obstetrical care has advanced over the last century, stillbirth still remains one of the most common adverse pregnancy outcomes, occurring in 1 in 160 deliveries in the U.S. My hope is that with this information shared here, we can work together to reduce it further.
Around two million stillbirths occur worldwide annually with approximately half being potentially preventable. The preventable stillbirths largely occur during the labor and delivery process. According to ACOG, a stillbirth, or fetal death, occurs when a fetus dies in utero after 20 weeks of pregnancy. Stillbirth is further classified as either early, late, or term.
- An early stillbirth is a fetal death occurring between 20 and 27 completed weeks of pregnancy.
- A late stillbirth occurs between 28 and 36 completed pregnancy weeks of pregnancy.
- A term stillbirth occurs between 37 or more completed pregnancy weeks of pregnancy.
According to the CDC, stillbirth occurred in 1 in 175 births with 21,000 babies stillborn in the U.S. in 2020. A more recent report found the following:
- In 2021, the total fetal mortality was 5.68, which was not significantly different from the rate of 5.74 in 2020. The rate also did not change significantly from 2019 (5.70) to 2020.
- The early fetal mortality rate (20–27weeks of gestation) was 2.93 in 2021, which was not significantly different from the rate in 2020 (2.97). The rate was also essentially unchanged from 2019 (2.98) to 2020.
- The late fetal mortality rate (28 weeks of gestation or more) was essentially unchanged from 2020 (2.78) to2021 (2.77). The rate was also not significantly different from 2019 (2.73) to 2020.
Factors that contribute to an increased risk of stillbirth
Stillbirth can occur in any pregnancy. However, there are certain factors that increase the risk of stillbirth. These include:
Race
Non-Hispanic Black persons have a stillbirth rate that is more than twice the rate of other racial groups (10.53 deaths per 1,000 live-births and stillbirths). In the U.S. the stillbirth rates for other groups were 4.88 for non-Hispanic white persons, 5.22 for Hispanic persons, 6.22 for American Indian or Alaska Native, and 4.68 for Asian or Pacific Islanders. Higher rates of stillbirth persist among non-Hispanic Black persons with adequate prenatal care due to higher rates of diabetes, hypertension, placental abruption, and premature rupture of membranes. More importantly, implicit and explicit bias and racism are implicated in many health disparities that affect the chance of a pregnancy ending in stillbirth in this population.
Past Obstetric History
Persons with a previous stillbirth have a 5X increased risk of recurrence in the next pregnancy. Persons with previous adverse pregnancy outcomes, such as preterm delivery, growth restriction, or preeclampsia, are also at risk of stillbirth in next pregnancies with a 1.2-2X increased risk.
Multiple Gestation
The stillbirth rate among twins is 2.5 times higher than in singletons (14.07 vs 5.65 per 1,000 live births and stillbirths). The risk of stillbirth increases in all twins with advancing gestational age. In addition, the risk is greater in monochorionic vs dichorionic twin gestations. The rate in triplet pregnancies is 30.53 per 1,000 live births. Causes of stillbirth in twin gestations include twin-twin transfusion syndrome, congenital anomalies (birth defects) and fetal growth restriction.
Maternal Age
Both younger and older maternal age (< 15 years and > 35 years) is an independent risk factor for stillbirth. Those of advanced maternal age are at increased risk due to an increased incidence of lethal congenital and chromosomal abnormalities in these pregnancies. The risk is further increased if the individual is of advanced maternal age and its their first pregnancy.
Maternal Obesity
Obesity (BMI >30) in pregnancy is associated with an increased risk of both early pregnancy loss and stillbirth.
Late-term and Post-term Pregnancies
Induction of labor for an indication of late-term (41 weeks to 41 weeks 6 days) and postterm pregnancy (42 weeks and beyond) is recommended after 42 0/7 weeks and can be considered at or after 41 weeks 0/7 due to an increased risk of stillbirth.
Medical Conditions
Acquired thrombophilias, like antiphospholipid antibody syndrome (APS), and comorbid medical conditions, including hypertension, diabetes (pregestational and gestational), systemic lupus erythematosus, renal disease, uncontrolled thyroid disease, and cholestasis of pregnancy, have been associated with and increased risk of stillbirth. In addition, excessive weight gain in pregnancy, substance use disorder, pregnancy via IVF and late-term and post-term gestational age are increase the risk of stillbirth.
Assisted Reproductive Technology
Pregnancies achieved by in vitro fertilization (IVF) appear to be associated with an elevated risk (two- to three-fold increase) of stillbirth even after controlling for age, parity, and multifetal gestations.
Substance Use
Maternal cocaine, methamphetamine, other illicit drug use, and smoking tobacco, are all significant contributors to abruption and stillbirth.
Placental abnormalities
Vascular abnormalities and abnormal placental villi anatomy contribute to an increased risk of stillbirth.
What you should do if you have risk factors
If any or some of these factors are present for you, speak with your physician directly about your concerns. You might be referred to a specialist for high-risk pregnancy to do closer monitoring of your pregnancy.
Get any preexisting medical conditions under optimal control
Optimal control of preexisting medical conditions like diabetes, hypertension, autoimmune disorders, mental health conditions, infectious diseases and thyroid disease is ideal. This includes optimal management of any medications used to control these conditions. Although we can try to play "catch up" during pregnancy to get these conditions under control, valuable time can be lost. If you have high blood blood pressure prior to pregnancy, you should start taking low dose aspirin (81 mg) at 12 weeks of pregnancy and continue until delivery to reduce your risk of preeclampsia.
Fetal kick counts
Your healthcare provider may also ask you to pay attention to fetal kick counting (FKC). Although fetal kick counting is easy and convenient, it is still unclear of kick counts are effective at preventing stillbirth. There are different ways fetal kick counts can be done, but they all involve encouragement of awareness of fetal movement patterns, being attentive to the complaint of reduced fetal movements, addressing the complaint in a systematic way, and the use of shared decision making to employ interventions safely. Ask your provider what they recommend. If the fetal movement is less than what is normal for your baby, you should let your provider know as soon as possible.
Sleep positioning
There is always a lot of talk on social media on sleep positioning or laying flat on your back for any reason and an increased risk of stillbirth. Laying flat o your back in the late second and third trimesters of pregnancy can cause a decrease in blood flow return to the maternal heart due to compression of the large inferior vena cava blood vessel that run alongside the spinal column behind the uterus. This large vein is responsible for blood flow returning to the maternal heart. Compression by the large uterus while laying flat on your back can reduce this blood flow return and reduce maternal cardiac output and uterine blood flow. This could result in decreased oxygenated blood flow to the placenta and fetus. Although any evidence linking sleeping flat on your back to stillbirth is largely base on case-control studies that are subject to significant bias. If possible, try to sleep with a tilt to your left side.
Delivery timing
Another measure to reduce stillbirth may include planning the timing of your delivery. Timing of the delivery must be balanced with the maternal and newborn risk of early term delivery with the risks of further continuation of the pregnancy.
Additional measures that may be taken:
- Detailed maternal medical and obstetric history
- Evaluation and workup of previous stillbirth
- Determination of recurrence risk
- Maternal smoking cessation counseling
- Genetic counseling if a family genetic condition exists
- Early diabetes screening is people with risk factors
- Acquired thrombophilia testing (lupus anticoagulant as well as IgG and IgM for both anticardiolipin and β2-glycoprotein antibodies) if medically indicated
Understanding your risk level and working closely with your healthcare provider can help keep you and baby safe. If you have experienced pregnancy loss or stillbirth, counseling and therapy can be extremely beneficial to help you work through the grief.
Testing available if you have a stillbirth
All cases of stillbirth should be offered the following:
- Fetal autopsy--Can provides additional clinical information in approximately 30% of cases.
- Placental pathology (gross and microscopic) including cord and membranes. This provides additional clinical information in approximately 30% of cases.
- Genetics testing can find abnormalities seen in 8% of cases.
- Lab testing includes: Kleihauer-Betke or flow cytometry at time of stillbirth, maternal syphilis testing, lupus anticoagulant, and antiphospholipid antibody testing (anticardiolipin, Beta-2 glycoprotein IgG and IgM antibodies with retesting in 12 weeks if positive).
If no other cause identified, the following can be added:
- Antiphospholipid antibody testing
- Fetal-maternal hemorrhage testing
If fetal growth restriction or a hypertensive disorder was present, the following can be added:
- Antiphospholipid antibody testing
- Fetal-maternal hemorrhage testing
If a fetal anomaly was known before delivery or found after delivery, the following can be added:
- Molecular genetics based on findings
Based on clinical indication:
- Indirect Coombs
- Glucose screening for LGA
- Maternal toxicology if abruption or suspected substance use disorder
Management of a subsequent pregnancy after a stillbirth
Antepartum fetal surveillance (AFS)
- If other medical comorbidities/conditions are present, AFS depends on the condition(s).
- If obesity is present (prepregnancy BMI of 35.0 to 39.9), weekly antenatal fetal surveillance starting at 37w0d can be considered. If the prepregnancy BMI is ≥40, weekly antenatal fetal surveillance at 34w0d can be considered.
- If a previous stillbirth at ≥32w0d, once or twice weekly AFS starting at 32w0d or start 1 to 2 weeks prior to gestational age of last stillbirth.
- If a previous stillbirth <32w0d, AFS is individualized.
- If no other indications for a growth ultrasound are present, a fetal growth ultrasound at 28 weeks to screen for fetal growth restriction can be considered.
Fetal kick counts (FKC)
- "Quickening" typically starts at 12-26 weeks. It feels like flutters or gas bubbles in your uterus. Actual fetal movements are reliably felt around 20-22 weeks. People who have had more than pregnancy can feel fetal movements earlier.
- Fetal kick counting is an inexpensive test of fetal well-being, but evidence of its effectiveness in preventing stillbirth is not established.
- FKCs are typically counted in a two-hour period of time. If there are less than 10 movements/kicks in that two hours, notify your provider.
- Pregnant individuals come to learn the movement patterns of their fetus over the course of the pregnancy. If you feel something is off, let your provider know.
- It is a common myth that the fetus moves less in the late third trimester because they "run out of room" to move. THIS IS NOT TRUE! If you ever feel that your fetus is not moving like they normally do, speak up!
Timing of delivery
- Delivery is recommended at 39w0d
- If other medical comorbidities/conditions are present, delivery is recommended according to those comorbidities/conditions.
- If maternal anxiety is present, an early term delivery (37 0/7 to 38 6/7) imay be considered after counseling on the increased fetal risks with early delivery.
Services that may be offered to you after experiencing a stillbirth
It is common for labor and delivery units to take pictures of you, your family and the baby after delivery. They will also make you a memory or keepsake box to take home. The one thing that I have found that many patients struggle with is whether or not they want to hold and spend time with the baby after birth. I can say one thing about this--I have never had a patient wish they had not held and spent time with the baby, but I have had patients regret not doing so.
Additional resources:
Management of Stillbirth, ACOG Obstetric Care Consensus Number 10
Stillbirth Management: The ACOG SMFM Consensus Document
Bereavement resources:
CDC: Stillbirth Support Resources
Postpartum Support International
International Stillbirth Alliance