If ten recommended interventions were 99 percent implemented in 68 priority [low and middle-income] countries, the number of stillbirths could be halved, said Professor Zulfiqar Ahmed Bhutta of the Aga Khan University Medical Centre in Karachi, Pakistan, author of one of a series of papers on stillbirth published in The Lancet medical journal papers.
Even if the interventions were 60% covered, stillbirths could be reduced by one-quarter. Some 2.64 million foetuses die after the 28th week of pregnancy, mostly in low- and middle-income countries.
Interventions include: basic and comprehensive emergency obstetric care; skilled care at birth; detection and management of foetal growth restriction; detection and management of hypertension in pregnancy; elective induction in post-term pregnancies; insecticide-treated bed nets and intermittent prophylaxis to prevent malaria; detection and treatment of syphilis; folic acid supplementation; and management of diabetes in pregnancy.
Stillbirths have largely been neglected in policy prioritizing for a variety of reasons. “There was little in terms of verified data for stillbirths and even less for its categories - whether intrapartum [during childbirth] or antepartum [before childbirth] - and risk factors, and little confidence that interventions could make a difference,” said Bhutta.
The Lancet series hopes to change this perception by re-framing stillbirths so that they are not seen as an unexplained event that occurs in the womb, but as something that is potentially preventable if appropriate care is given during pregnancy and birth.
Bhutta suggested in his paper that cheaper solutions, such as improving antenatal care, preventing malaria, detecting and treating syphilis, be adopted immediately, while more expensive interventions, such as training health workers, and procuring equipment for emergency births, could be built up gradually.
Other interventions would require improved long-term funding allocations, including addressing hypertension, diabetes, post-term pregnancy (which lasts longer than usual) and monitoring foetal growth problems.
Providing skilled attendants at birth would reduce intrapartum stillbirths by about 23 percent, said Dr Joy Lawn, of NGO Save the Children, making it the most effective single intervention. Almost half the women in low- and middle-income countries give birth at home, without any skilled assistance.
Voucher schemes or conditional cash transfers could be used to encourage women to have their babies in a facility, since in settings where the highest infant mortality occurs, only half of all births take place in facilities.
In high-income countries, where most women receive fairly good quality care while giving birth, the proportion of stillbirths is less than 10 percent of all births.
Sub-Saharan Africa, which has a scarcity of skilled birth attendants, has been making swifter progress than Asia in encouraging women to give birth in a facility. “One year ago, the international community became acutely nervous about the lack of progress on reducing maternal mortality,” Lawn said.
A year later, maternal mortality in sub-Saharan Africa had fallen by 2.6 percent. “This marks significant progress… For stillbirths, a lot of the focus in high-income countries has been because parents have called for it. Setting a global policy goal is one good way of getting it on the agenda.”
One-third of African countries could meet the Millennium Development Goal to reduce childhood mortality (Goal Four) and to improve maternal health (Goal Five), which would also reduce stillbirths.
Some investments in reducing maternal mortality are already having a positive effect on the number of stillbirths, but these results are not given due significance. “Governments could argue for more investment if they counted stillbirths in the work they’re already doing,” Lawn told IRIN.
Saving mothers’ lives costs $23,000 per death averted, but if stillbirths and neonatal deaths are included, the figure drops to $2,700 per life saved. “Our single message is, ‘Care at birth may be more expensive, but it gives you the biggest bang for your same buck if you count it properly’.”