Article published on The New York Times
I had been in active labor for 12 hours when my obstetrician said he would have to do a Caesarean because Twin A was stuck and neither twin could emerge naturally. Terrified of losing either baby, I responded, “I don’t care if I cough them up, just get them out alive!”
Which, thankfully, he did — almost 42 years ago.
Alas, not every woman is so lucky. Even with the highly advanced technology now available to monitor the unborn, each year 27,000 fetuses that pass the 20th week of gestation and 13,000 that reach the 28th week or beyond are born dead. One in every 200 pregnant women who gets to 22 weeks of gestation will have a stillborn baby.
It often is a devastating experience. “As soon as they learn they are pregnant, most women consider their unborn baby their child, and for many a stillbirth is like the death of a child,” said Dr. Robert Goldenberg, an obstetrician-gynecologist at Drexel University College of Medicine.
Though stillbirths have declined sharply since the 1940s, they remain very much with us, and not just among women who are poor or poorly educated or lack access to good medical care. Even under the best of circumstances, sometimes babies just don’t make it.
And, as Dr. Zoe Mullan and Dr. Richard Horton wrote recently in the British medical journal The Lancet, “The grief of a stillbirth is unlike any other form of grief: the months of excitement and expectation, planning, eager questions and the drama of labor — all magnifying the devastating incomprehension of giving birth to a baby bearing no signs of life.”
With financing primarily from the Bill and Melinda Gates Foundation, the journal has published online a major series of reports on the global problem of stillbirths, more than 2.6 million of which occur each year. Though all but 2 percent take place in low- and middle-income countries, “stillbirths also continue to blight wealthy nations, with around one in every 320 babies stillborn in high-income countries,” Lancet editors noted.
Yet society does little to acknowledge these losses, and friends and relatives tend to avoid talking about them.
Calling stillbirth “one of the last taboos — the death of a baby before birth somehow considered not to count,” Janet Scott of the Stillbirth and Neonatal Death Charity in London wrote that “in high-income countries, although infant mortality rates have dropped, stillbirth rates have not changed in more than a decade.”
Many Known Causes
Adding to parental devastation is the usual mystery of why a stillbirth occurred. In only about 40 percent of stillbirths is there an explanation, according to Dr. Goldenberg, an author of the Lancet series.
Yet, he said in an interview, “when a careful autopsy is performed of both the baby and placenta and the baby’s chromosomes are examined, we can find an explanation 80 to 85 percent of the time.”
Dr. Goldenberg added, “Many of the tests that could clarify why a baby died are not done because the doctor and family feel badly, because the parents believe the baby has suffered enough and don’t want it disturbed any further, or because the hospital gets no extra payment for an autopsy.”
Still, there are a number of known causes, some of which have increased in recent years. In the Lancet report, Australian and British researchers listed maternal overweight andobesity as the most important preventable risk factor in high-income countries, accounting for up to 18 percent of stillbirths. Second and third, the authors wrote, are maternal age over 35 and smoking during pregnancy, the latter being more common among the poor.
Women over 35 face a 65 percent increase in the odds of a stillbirth, compared with younger women. And, the researchers noted, “the number of women delaying childbearing is rising, which is leading to a growing proportion” of women over 35 having their first babies. First babies themselves are more likely to be stillborn.
In vitro fertilization resulting in multiple pregnancies is yet another factor that has become more common in recent years. “Without question,” Dr. Goldenberg said, “twinsand triplets have much higher rates of stillbirth.” To reduce the risk, he strongly recommended that, when attempting an in vitro pregnancy, only one embryo be implanted.
While being overweight is in itself a risk factor for stillbirth, Dr. Goldenberg said it also increased the risk of two other causes, gestational diabetes and pre-eclampsia (high blood pressure brought on by pregnancy). Women with diabetes or high blood pressure before becoming pregnant are also at higher risk for stillbirth, especially if their conditions are poorly controlled.
Another potentially preventable cause is infection, especially untreated periodontal disease, which should be corrected before a woman becomes pregnant, Dr. Goldenberg suggested. Studies thus far have not shown a clear benefit of periodontal treatment during pregnancy. Still, when a blood-borne infection from any cause is diagnosed, treatment with antibiotics may reduce the chances of a stillbirth.
Balancing the Risks
If a pregnancy goes well past term, defined as 40 weeks for a singleton and 38 weeks for twins, the risk of stillbirth rises. The Lancet authors recommended that women who are still pregnant after 41 weeks undergo induced labor.
Of course, this means a woman’s due date must be accurately determined, usually by a “dating” ultrasound exam early in pregnancy. Some causes of stillbirth — like placental abnormalities and fetal growth retardation — are not preventable but can be monitored and, if necessary, “treated” with early delivery to save the infant. Low-dose aspirin can reduce the risk associated with some placental problems.
“In the United States, growth-retarded babies don’t have to die,” Dr. Goldenberg said. Monitoring factors like fetal movements and blood flow through the placenta can show which babies are in trouble and should be delivered early.
“We have to balance the risk of prematurity with the risk of stillbirth,” he said.
His own first grandchild was born early this way. At 28 weeks gestation, the baby’s mother developed pre-eclampsia and the baby’s growth was retarded. The pregnancy was monitored closely for four more weeks, when it was decided that an early delivery was safer than risking stillbirth. Now 16 months old, Dr. Goldenberg’s granddaughter is “just wonderful,” he said.
Unfortunately, many women in this country lack access to the kind of care his daughter-in-law received. As a result of medical inequities, the risk of stillbirth is nearly twice as high among African-American women as among white and Hispanic women, the Lancet report stated. Rural women, too, are at a relative disadvantage compared with urban women.
Dr. Goldenberg said that if the new health care law gets more women into care early in pregnancy, there should be a positive effect on stillbirth, which currently occurs 10 times as often as sudden infant death syndrome in the United States.