Stillbirth is still a problem despite advances in obstetrical care
Thanks to early diagnostics, advancements in testing, and increased knowledge by both physicians and patients, we are now able to deliver more healthy babies to healthy parents than in the past. However, even as medicine 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.
The U.S. National Center for Health Statistics defines stillbirth (formally called fetal death) as the delivery of a fetus showing no signs of life as indicated by the absence of breathing, heartbeats, pulsation of the umbilical cord, or definite movements of voluntary muscles. There are approximately 23,600 stillbirths at 20 weeks or greater reported annually.
Factors that contribute to stillbirth
There are many factors that contribute to stillbirth. (Resource: ACOG)
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; this has been attributed to higher rates of diabetes mellitus, hypertension, placental abruption, and premature rupture of membranes. Implicit and explicit bias and racism are implicated in many health disparities including perinatal morbidity and mortality.
Past Obstetric History- Persons with a previous stillbirth are at increased risk of recurrence. Compared with persons with no history of stillbirth, persons who have had a stillbirth had an increased risk in subsequent pregnancies. Persons with previous adverse pregnancy outcomes, such as preterm delivery, growth restriction, or preeclampsia, are at increased risk of stillbirth in next pregnancies.
Multiple Gestation- The stillbirth rate among twins is approx. 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. Higher rates are due to complications specific to multiple gestation (such as TTTS), and increased risks of aneuploidy, congenital anomalies, and growth restriction.
Age- Age at either end of the reproductive age spectrum (< 15 years and > 35 years) is an independent risk factor for stillbirth. Large observational studies demonstrate that advanced age is an independent risk factor for stillbirth even after controlling for risk factors such as hypertension, diabetes, placenta previa, and multiple gestation.
Obesity- Obesity in pregnancy is associated with an increased risk of early fetal loss and stillbirth. A comprehensive study of five high-income countries found that maternal overweight and obesity (BMI > 25) was the most common modifiable risk factor for stillbirth.
Late-term and Postterm Pregnancies- induction of labor for an indication of late-term and postterm pregnancy is recommended after 42 0/7 weeks and can be considered at or after 41 weeks 0/7.
Medical Conditions- this includes antiphospholipid antibody syndrome (APS) which is an acquired thrombophilia, and comorbid medical conditions including hypertension, diabetes, systemic lupus erythematosus, renal disease, uncontrolled thyroid disease, and cholestasis of pregnancy have been associated with stillbirth.
Assisted Reproductive Medical Technology- Pregnancies achieved by in vitro fertilization (IVF) appear to be associated with an elevated risk (two-fold to threefold increase) of stillbirth even after controlling for age, parity, and multifetal gestations.
What should you do if you have any of these 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 the baby along the pregnancy. During these high-risk pregnancy appointments, the physicians will be able to monitor the baby’s growth and development more closely and make decisions about your and baby’s care.
Your healthcare provider may ask you to pay attention to fetal kick counting (FKC). If the fetal movement is less than what is normal for your baby, your health care professional may ask you to keep track of the fetus’s movements. You can do fetal kick counts at home, and there are different ways kick counts can be done. Ask your provider what they recommend. Another measure to reduce stillbirth may include timing 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 medical and obstetric history
Evaluation and workup of previous stillbirth
Determination of recurrence risk
Genetic counseling if family genetic condition exists
Acquired thrombophilia testing: lupus anticoagulant as well as IgG and IgM for both anticardiolipin and β2-glycoprotein antibodies
Support and reassurance
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.
Shannon M. Clark, MD, MMS is a double board certified ObGyn and Maternal-Fetal Medicine Specialist, and founder of Babies After 35. In her roles as a clinician, educator and researcher at UTMB-Galveston, she focuses on the care of people with maternal and/or fetal complications of pregnancy. Dr. Clark has taken a special interest in pregnancy after the age of 35, which according to age alone, is considered a high-risk pregnancy.