Maternal and child deaths have received significant attention in the effort to meet the Millennium Development Goals by the end of 2015, but stillbirths have been severely neglected. Stillbirth targets were omitted from these goals and remain absent from the post-2015 Sustainable Development Goals.
Giving birth to a stillborn infant is one of the most heart-breaking and tragic events for any parent and their family. These babies die either during pregnancy or during the process of giving birth. Deaths earlier than 28 weeks are called miscarriages.
Of the stillbirths that happen across the globe, 98% occur in low- and middle-income countries. The World Health Organisation has stressed the importance of ending these preventable deaths. Its Every Newborn action plan, launched in 2014, sets a global target to reduce stillbirth rates to ten for every 1000 births by 2035.
South Africa, as a signatory to the plan, has set a national target of achieving this by 2016. While progress has been made in reducing the number of stillbirths, the current rate of 18 stillbirths for every 1000 births is still too high.
In a ranking of stillbirths in 193 countries by the Lancet medical journal, South Africa was placed 148. Comparatively, this is worse than Brazil at 79, Russia at 80 and China at 82, but better than India at 154 and Nigeria at 192.
Risk factors in stillbirths
The causes of stillbirths are closely connected to the same influences that affect maternal and newborn mortality. Many of the risk factors are, however, often identified too late, if at all.
Women over the age of 34 have a greater risk of pregnancy-related complications, including stillbirths. Conditions such as high blood pressure and diabetes account for about a quarter of stillbirths before the onset of labour. Obesity is also a risk factor.
Once a woman goes into labour, good clinical management is critical because half of stillbirths at this stage result from maternal bleeding and insufficient oxygen to the baby.
How interventions would help
There are various efforts to reduce stillbirths implemented at various levels of quality and coverage in South Africa.
Our research has modelled the impact and cost of ambitiously scaling interventions to full coverage at high quality.
These include detecting and treating HIV earlier in pregnant women, managing their hypertension and diabetes better and improving both essential and emergency obstetric care during labour and delivery. With the rapid escalation of obesity in South Africa – particularly in in young teenage girls – one key to preventing stillbirths is good nutrition well before pregnancy.
Of the interventions modelled, improved labour and delivery management would have the highest impact and could potentially avert 60% of the stillbirths.
Scaling up these interventions could prevent an additional 5400 stillbirths each year. The interventions would also prevent additional deaths of 1300 mothers and 4900 newborns, resulting in a triple return on investment. South Africa’s stillbirth rate would reduce by 30%, meeting the World Health Organisation’s interim goal for 2030.
The full intervention package is affordable and would cost the country an additional R850 million annually – or R16 per person. This amounts to little more than 0.5% of the total health budget and would make an enormous difference.
Fixing the problems
But in addition to providing access to services, there are three more challenges that need attention if South Africa wants to reduce its stillbirth rates.
First, the quality of care is crucial. Although the majority of women give birth in health centres and hospitals, many women and babies die due to delays in accessing services. At the centre of improving and monitoring quality will be the newly created Office of Health Standards Compliance, whose evaluations will impact whether health facilities receive funding and accreditation under the planned National Health Insurance.
The compliance office has identified cleanliness, infection prevention, reduced waiting times, drug availability and improved staff attitudes as immediate priorities. All of these would improve labour and delivery management. But more effort is needed on the demand side in communities to empower and enable families to recognise danger signs and seek care promptly.
Second, more research is necessary to understand the causes of stillbirths before labour, half of which are occurring for unknown reasons. Even in high-income countries, many stillbirths do not undergo a medical autopsy and there is a reluctance to perform additional tests to determine the cause of death. These questions are difficult for families who want answers.
Finally, there is a high degree of under-reporting. In many countries stillbirths do not appear in any official statistics. In South Africa, stillbirths can and should be captured through vital registration by the Department of Home Affairs, but these deaths are not always registered by the families.
One possible reason for not registering these stillbirths may be that families can then avoid the high costs associated with a formal burial. Others may feel a stigma about reporting stillbirths that occur at home. More advocacy is needed to inform families and training for health care workers about the importance of counting every birth and death.
Added to this, the grieving from a stillbirth is often left to the mother to shoulder alone and in silence. Providing support services is a missing link and community health workers could be important if sufficient guidance is provided.
While some causes of stillbirth are unknown, many of the deaths are preventable. For South Africa to fulfil its promise as a signatory to the World Health Organisation’s stillbirth alleviation plan, it needs to prioritise stillbirth prevention and related interventions to ensure it meets its targets.
Priceless researcher Julia Michalow assisted in the research and writing of this article.