Finding the cause of stillbirth in low-resource settings: time for ‘business unusual’?

Annually, an estimated 2.6 million stillbirths occur worldwide. The vast majority (98%) occur in low- and middle-income countries (LMIC). This has also been called the ‘silent epidemic’, causing untold emotional pain to many families. Sadly, mothers who had a stillbirth are also much more likely to have another in the future than those who did not.

Most stillbirths in LMIC are preventable through the provision of quality care for all mothers and babies. To be effective, interventions to reduce global stillbirths need more up-to-date information about the cause of stillbirth. However, there is still a lack of good data on why stillbirths occur, particularly from sub-Saharan Africa.

An autopsy is often considered to be the “gold standard” for investigating the cause of stillbirth. However, most hospitals in LMIC lack the resources required to conduct an autopsy. Even in high-income countries, many parents do not wish their stillborn baby to undergo a full autopsy. Thus, the rejection rate is high.

In most settings, including in LMIC, when a baby is stillborn, a review is organised where the circumstances that led to the stillbirth are discussed and any clinical records and tests are reviewed. This is usually conducted by healthcare providers themselves - including specifically assigned ‘assessors’ - who are trained to analyse the available information to assign a cause of death and factors contributing to the death. This process is called ‘stillbirth audit’ or ‘stillbirth review’.

Stillbirth audit provides valuable information for the parents as well as the healthcare providers. Where the quality of care could have been improved, recommendations for change in practice are made. One of the major challenges of stillbirth audit is that in LMIC settings the cause of death remains ‘unknown’ for a substantial proportion of cases. This is often because the only sources of information are the clinical records of the mother and these may not include enough information, especially if diagnostic tests are not available. In practice, the cause of death is not really known for up to 50% of stillbirths.

Since autopsy is out of reach in many low-resource settings and death audit yield a high proportion of cases with an unknown cause, it makes one wonder: how can we improve diagnosis of the cause of stillbirth?

Various non-invasive methods that could be used in LMIC and are more likely to yield more information have been tried. These include taking an anonymised photograph of the stillborn baby to assess any externally recognisable abnormality or disease and to better understand the time of death (e.g. whether this occurred in the womb or during birth); as well as an examination of the placenta and histopathological tests.

The low cost and ease of use of these methods make them promising in low-resource settings. However, there is currently limited evidence regarding their contribution to the identification of the cause of death, i.e. if they could reduce the proportion of cases with unknown cause. Therefore, researchers in this area should focus on gathering more data to work out if it is feasible and effective to use to use these methods on a much larger scale.

Perinatal death review can also be quite subjective. In many LMIC, if a perinatal death audit is conducted, it is done by the same group of clinicians who took part in the clinical management of the case. Reviewers can be biased in their assessment of the cause of death as well as the time of death. If stillbirth review can be done in a ‘no shame no blame’ environment, then action plans can be developed to address the real factors contributing to the death.

To address this last point, the Centre for Maternal and Newborn Health (CMNH) is working with experts from across the world to develop computer algorithms, which will then be used to develop mobile device apps that could help healthcare providers in LMIC to conduct perinatal death audit with minimal human interference and bias.

Furthermore, the CMNH has developed research protocols to conduct research to work out which additional diagnostic tests would be useful and effective. It is hoped that this will not only improve diagnoses of causes of stillbirth, but also provide information to support parents especially with regard to giving them better information about what happened and if that could affect subsequent pregnancies.

 

About the author
Dr Mamuda Aminu is a Senior Clinical Research Associate at the Centre for Maternal and Newborn Health, with a research interest in quality improvement and perinatal epidemiology.

 

Main photo credit: UN Photo/Kibae Park Dhaka, Bangladesh 2010. Courtesy of Flickr.