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Stillbirths: Why it is still a big problem
What you need to know:
Every day, more than 7,200 babies are stillborn globally, according to the World Health Organisation, with most of the deaths occurring in developing countries like Uganda. The major causes of these deaths are childbirth complications, maternal infections in pregnancy, maternal disorders (especially hypertension and diabetes), foetal growth restriction and congenital abnormalities.
After nine months of pregnancy, a mother comes into labour with a foetal heartbeat, baby clothes, determination to endure the labour pains and an expectation to return home with a bouncing baby. Except in this case, she returns with no baby.
This is how Patrick Aliganyira, a programme specialist with Saving Newborn Lives, a project of Save the Children, explains the dilemma of a mother who has had a stillbirth.
Reduction of child mortality rate and improvement of maternal health is one of the United Nations Millennium Development Goals, but there is no mention of reduction in stillbirths or newborns.
Dr Juliet Birungi, gyneacologist at Mulago National Referral Hospital, defines stillbirth as delivery of a dead foetus after 28 weeks (roughly six months) of gestation. She says: “The period of gestation is expressed in terms of weeks because different months have varying weeks.”
A stillbirth can be termed as fresh or macerated. A fresh stillbirth is when the baby in the womb dies a few minutes or hours before it is delivered. On the other hand, a macerated stillbirth is where the foetus dies long before its delivery.
“When a baby dies at four months, that is, before 28 weeks of development, this is not considered a stillbirth but rather a missed abortion,” says Dr Birungi.
She says a missed abortion is similar to a miscarriage, but does not involve bleeding or passage of tissue through the vagina. It is usually diagnosed during an ultra sound scan and a blood test.
Causes of stillbirths
According to Dr Birungi, 25 to 60 per cent of the causes of stillbirths are not known, however, they can be categorised into maternal, foetal and placental causes.
Maternal causes
Maternal causes are factors to do with the mother that lead to foetal death. Some of the maternal causes, according to Dr Birungi, and Grace Aceng, the in-charge midwife at Kal Ali Health Centre II, in Gulu District can include the following:
Infections
Infections such as syphilis, gonorrhea, malaria can lead to a mother having a stillbirth. Aceng explains, “These infections can attack the uterus and destroy its membrane, leading to death of the baby.”
High blood pressure
Pre-eclampsia is a condition that causes a mother to get high blood pressure. “When the mother’s blood pressure goes up, this can cause abnormalities in the placental nutrient supply to the foetus and placental abruption due to seizures that result from high levels of blood pressure,” explains Dr Birungi. With little nutrient supply, the foetus dies.
Maternal anaemia
Anaemia is a condition when a person does not have sufficient iron in the body. Anaemia results in lack of enough oxygen supply to the foetus, thereby leading to death.
Prolonged pregnancy
This is pregnancy that lasts for more than 42 weeks, and can lead to foetal death because the baby grows bigger than the nutrient supply it has in the womb. “The amniotic fluid volume reduces and the foetus dies. Also, the placenta undergoes changes which lead to insufficient nutrient supply for the foetus,” explains Dr Birungi.
Amniotic fluid acts as a shock absorber to any force that may push the mother’s uterus, keeps the baby warm, aids the growth of the baby’s digestion and promotes muscle development.
Placental abruption
Placental abruption is when the placenta separates from the lining of the uterus before delivery of the baby. “At times, bleeding from this separation is concealed or revealed with abdominal pain,” says Dr Birungi
Umbilical cord accidents
If the cord ties around the foetus’ neck or when the cord is too short or too long, can increase the risk of death. “In most cases, when the cord is around the foetus’ neck, the mother delivers normally under close supervision of a doctor or midwife. However, in a few cases, when the cord is too tight, it can be a risk factor for death,” Dr Birungi notes.
Why stillbirths are still high
A nurse bathes a newborn baby at Mulago National Referral Hospital. Health workers say most stillbirths occur when a woman is in labour. Strengthening maternal, newborn, and child health programmes can help reduce cases of such deaths. PHOTO by Rachel Mabala
Apart from looking to health facilities and the quality of health care in Uganda, Aliganyira says the high stillbirth rate can be attributed to societal perception and acceptance of this issue. “Most Ugandans have come to accept stillbirths and many do not consider it loss of a child or life when a baby is born dead.
There is no value attached to a baby that is born dead, and because of this attitude, there is no attention being paid to stillbirths yet it greatly affects the progress we make in reducing newborn mortality.”
Other factors that have kept stillbirth case high include lack of sufficient equipment in health facilities, few health workers, infections such as syphilis, malaria, domestic violence and poor maternal nutrition.
Preventive measures
Some of the ways to prevent stillbirths as identified by Dr Birungi and Aceng include the following:
Starting antenatal care early gives mothers a chance to be educated on the danger signs they should lookout for in pregnancy and what to do when they notice unusual changes with their pregnancy.
“Before conceiving, mothers should go for pre-natal care and advice on what to expect when they become pregnant,” says Dr Birungi. She says a well-balanced diet also plays a crucial role in the outcome of a pregnancy. This is especially crucial at the time of labour because the mother will need a lot of energy to be able to push the baby.
In case, a mother has an infection, the health workers advise that they need to seek treatment early enough before the condition becomes dangerous and puts both the mother and child at risk.
“Mothers should monitor foetal movements and report to the doctor if they have reduced or are not present,” says Dr Birungi.
expert say
“Patrick Aliganyira, a programme specialist with Saving Newborn Lives, a project of Save the Children, says most Ugandans have come to accept stillbirths and many do not consider it loss of a child or life when a baby is born dead.
There is no value attached to a baby that is born dead, and because of this attitude, there is no attention being paid to stillbirths yet it greatly affects the progress we make in reducing newborn mortality.”
Other factors include few health workers, infections such as syphilis, malaria, domestic violence and poor maternal nutrition.
The counsellor’s advice
Winnie Namusoke a counselling psychologist with Hope in Life Counselling Services, says when a woman has a stillbirth, it causes a lot of distress that cannot be overcome in a short time. “Such a mother is always thinking about how she carried the baby for nine months, and what could have gone wrong to cause its death,” says Namusoke.
She says a mother who has had a stillbirth is likely to become unsettled, anxious and worried about whether she will ever conceive or give birth again.
This anxiety could result in conditions such as high blood pressure, depression and unhealthy coping mechanisms including resorting to alcoholism. “Normally, a woman who has had a stillbirth will mourn her loss for some time, and then move on with her normal life.
On the other hand, abnormal grief is when such a mother withdraws from people, keeps to herself, or even develops suicidal tendencies,” explains Namusoke. In some cases, stillbirths can lead to marital conflict especially in cases where the husband was against his wife working or doing certain things that increased her risk of having a stillbirth.
How to heal
Namusoke offers these tips as a coping mechanism.
•The mother should accept the loss of her baby and come to terms with it. She should not apportion blame as to who contributed to the loss.
•She should look up to God to clear the uncertainty of whether she will conceive again or not.
•Follow-up with the doctors is necessary. A mother who has had a stillbirth should also adhere to medical treatment as prescribed by the doctor.
•A mother who is recovering aftera stillbirth should get enough rest, so that she does not develop complications such as high blood pressure.
•Joining a social support group is important as it helps a grieving mother share her pain with friends.
One woman’s experience of having a stillbirth
My name is *Irene Namaganda. I got pregnant for the first in July 2013. Although I vomited a lot in the first three months, the pregnancy was progressing well. At five months, my feet and body started swelling. When I went to the hospital and underwent a check-up, the doctors said I had high blood pressure, a condition I did not have before I conceived.
The doctor suggested I have the baby removed when I was seven months pregnant but I refused.
When the pregnancy was nine months, I started to experience pain in my stomach but I did not know it was the labour pains since I have never been pregnant.
I alerted my mother about my condition and she said I was due for delivery. We reached hospital at 5am and when the doctor on duty examined me, she informed me the baby was five centimetres out, and that I was in the last stages of having the baby come out.
I was examined further and it was discovered my blood pressure levels were high.
When the doctor arrived at about 7am, with my pressure still high, he recommended that I be taken to the theatre for an emergency operation. As I was being taken to the theatre, I inquired how my baby was doing from the doctor.
He said it was impossible to tell me at that moment. I was in theatre at about 8am, and spent 30 minutes without any activity going on. The doctor in theatre said he had no authorisation letter to carry out an operation on me, and recommended a scan to find out how the baby was doing.
I was taken out of the theatre for a scan, which showed the baby was dead in my womb. I was in shock that I had lost my baby. I was so weak, hopeless with a dead baby in my womb.
I felt irritated, scared and in pain at the same time. One of the nurses advised against undergoing a caesarean section because she says the scar would remind me of my baby’s loss.
I was induced by drip which gave me strength to push the baby out. I chose not to look at what would have been my baby, but my mother said it was a baby boy.
It took a month for my body to adjust to its original size, but I would cry whenever I looked at the things we had bought for the child.
My husband was also hurt because instead of a baby, we were given a dead body to take home for burial.
I know if the midwives and doctors had not taken so much time debating whether I should undergo an emergency operation or not, my baby would have survived.
*Not real name
Warning signs of stillbirth
Dr Juliet Birungi, a gynaeacologist at Mulago National Referral Hospital, says one of the signs of a stillbirth is when a mother experiences reduced or non-foetal movement.
The mother and doctor might also discover there is no heartbeat during an ultra sound scan.
That is why expectant mothers are usually encouraged to undergo scans to monitor the growth of the baby in the womb. At times, the mother’s womb does not grow as expected because the foetus is long dead. Dr Birungi says when a foetus is discovered dead, the mother and her family are counselled and an examination is carried out to establish whether there was bleeding or not.
“If the mother does not have any identifiable medical condition, the risks will set in within two weeks. It is during this period that tissue factors from the dead foetus get into the mother’s blood, causing bleeding and putting her at risk,” says Dr Birungi.
