An unusually high number of stillbirths and infant deaths at a Victorian regional hospital has stirred up a grim topic often hidden from public view. A review of ten of these deaths occurring in 2013 and 2014 found that seven may have been avoidable.
The death of an unborn baby is a devastating and traumatic event, with long-lasting psychological, social and economic impacts on parents, families and society. In Australia, around 2,225 stillbirths occur each year.
The majority of these deaths are not fully, diagnostically investigated, while some remain unexplained despite thorough investigation. Although there are beliefs stillbirth is “nature’s way” and therefore “meant to be”, many stillbirths are preventable with improved health and quality care.
Causes and risk factors
In Australia, stillbirth is defined as the death of a baby of at least 20 weeks’ gestation or 400 grams in weight. Most stillbirths occur in the antenatal period.
Causes of death can include infection, the mother’s health, haemorrhage, spontaneous preterm birth and congenital abnormality.
In high-income countries, no definitive cause is found in around 30% of stillbirth cases. But mothers most at risk include those who are older, smokers, those with obesity and diabetes, and women with a past history of stillbirth.
Problems with the placenta that restrict blood and nutrient flow from the mother to the baby, called placental insufficiency, are strongly linked with stillbirth. Fetal growth restriction, twin or multiple pregnancy, ethnicity and social disadvantage, can also play a part.
However, many women who have a stillborn baby have no identifiable risk factors. And in a some cases, substandard care can be to blame.
Substandard care appears to more commonly contribute to stillbirths during labour and birth. A Dutch study showed inadequate care may have played a part in around 30% of stillbirths.
A 2010 confidential enquiry in the United Kingdom found the majority of reviewed infant deaths at birth had “contributing factors”, some of which may have lead directly to the death of the baby. While in New Zealand, adequate care could have prevented 19% of stillbirths in 2013.
Concerns about care in the UK report included failures to identify signs of poor health (such as poor growth of the baby), misinterpretation of the fetal heart rate, failure to consult senior staff, and poor communication between care providers or with the mother.
Failure to follow clinical practice guidelines and poor communication is most common in substandard care. Low antenatal care attendance and poor management of the mother’s health conditions, such as diabetes, are also instances of inadequate care.
There are a number of ways to investigate the causes of stillbirth. As the gold standard, it is recommended all parents be offered an autopsy of the baby and examination of placental tissue to look for abnormalities that may weaken placental function.
But some parents don’t consent to an autopsy, while others are not approached at all about the possibility. Some are not appropriately counselled to help them make an informed decision about whether to have the autopsy.
Tests such as these are also limited in availability due to high costs as well as access to equipment and expertise.
Several rights and legal groups are advocating to incorporate stillbirths into states' Coroner’s Acts for their cause to be determined through a Coronial inquest.
But this is not the most appropriate way of investigating stillbirths, for a number of reasons.
First, the purpose of the Coroner is to determine whether the cause of a death is natural or caused by accident or injury. Because the majority of stillbirths aren’t a result of the latter, and have an obvious cause, they wouldn’t fulfil the requirement of this determination.
Further, a Coronial inquest would mean the autopsy would generally be performed by a forensic pathologist rather than a more suitable, skilled perinatal pathologist.
And most importantly, there are significant disadvantages for women and their families. The major limiting factor to autopsy being performed in the case of a stillbirth is parental consent, as many don’t wish their child to undergo this procedure.
The inquest – which would have the bereaved family separated from the child immediately after birth – would take the choice away from parents and surely add to their emotional turmoil.
And while autopsy is the gold standard test (along with placental pathology) there are alternatives to autopsy which are often helpful in understanding why the baby died.
The Perinatal Society of Australia and New Zealand sets out recommendations for maternity services to investigate and clinically audit stillbirths and neonatal deaths.
These audits should be conducted by the health service responsible, with an external expert panel doing an in-depth review. This review must be underpinned by comprehensive information about the death.
Victoria is currently introducing a state-wide perinatal autopsy service to ensure high-level advice on the appropriate investigations is given and appropriate support and counselling can be set in place for families.
For the cases of unexpected stillbirths in late pregnancy, there will be a requirement under the regulations of the Act that governs the Consultative Council on Obstetric and Paediatric Mortality and Morbidity, that these deaths are notified within 48 hours.
Norway introduced perinatal mortality audits such as these, which have been associated with improved care and less perinatal deaths.
In 2011 the Lancet’s stillbirths series urged all high-income countries to implement routine perinatal mortality audits, governed at the national level. Despite this call, only a handful of countries have such programs in operation.
Vicki Flenady, Associate Professor, School of Medicine, School of Population Health, and School of Nursing and Midwifery, The University of Queensland; Aleena Wojcieszek, Research Officer, Stillbirth Prevention Group, Mater Research Institute, The University of Queensland, and David Ellwood, Professor of Obstetrics & Gynaecology, Griffith University