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EFFORTS to discover the underlying mechanisms of stillbirth have gained new urgency following an Australian study showing the risk of stillbirth varies significantly according to a mother’s country of origin.
The research, in this week’s MJA, found that women born in South Asia had more than double the risk of a stillbirth late in pregnancy, compared with women born in Australia. (1)
The authors found the rate of late-pregnancy stillbirth among South Asian-born women was 3.55 per 1000 births, compared with only 1.48 among Australian-born women and 1.06 among women born in South-East Asia or East Asia. The findings were based on data from more than 44 000 births at three public hospitals in Melbourne between 2001 and 2011.
There were some differences in risk factors for stillbirth between South Asian-born women and Australian-born women, but these differences did not explain the increased stillbirth rate in South Asian-born women, which suggested other causative mechanisms, the study authors wrote.
“In a racially diverse country like Australia, we believe that uncovering those mechanisms will be necessary to secure improvements in perinatal outcomes for all women”, they wrote.
In an editorial in the same issue, members of the Australian and New Zealand Stillbirth Alliance, Associate Professor Vicki Flenady and Professor David Ellwood, called for improved data quality to better inform stillborn prevention strategies. (2)
They noted that 20% of stillbirths remained unexplained. “Despite the availability of nationally endorsed guidelines, a lack of appropriate evaluation of the causes of stillbirth still plagues prevention efforts”, they wrote.
They noted that autopsy — the gold standard for investigating the cause of stillbirth — was often not performed.
Professor Ellwood told MJA InSight that there were lots of reasons for this — including cultural and inadequate explanation to parents about how autopsy might help.
He said even when stillbirths were properly investigated some remained unexplained and more research was needed in this area.
“We don’t know enough about what might affect placental function in late pregnancy. This is one very significant factor that needs more research”, Professor Ellwood said.
To really understand the national picture, all stillbirths needed to be properly investigated and classified.
“It’s only when you get that kind of systematic data that you start to understand the underlying mechanisms and develop interventions”, he said.
The study also underlined the need for doctors to identify which patients might be at higher risk of stillbirth as this could change how they managed their pregnancies.
The MJA researchers said their findings supported this approach. “Our data confirm that the relative risk of stillbirth in South Asian-born women increases with advancing gestation, supporting consideration of an ethnicity-based intervention policy”, they wrote.
They suggested fetal surveillance or induction of labour being considered at an earlier gestation in South Asian-born women.
The authors also said the use of fetal growth charts customised by maternal characteristics, including ethnicity, were based on the premise that differences in birthweight related to maternal attributes that were physiological, not pathological.
“This may well be false”, they wrote. “Indeed, if applied to a South Asian population, customised growth charts may impair the detection of fetal growth restriction and so increase the risk of stillbirth.”
According to a letter published in the same issue of the MJA, further research was also needed to understand family perspectives on maternity care following stillbirth. (3)
“It must move beyond the question of whether seeing and holding a stillborn baby might be associated with a particular outcome, and focus on contextual factors that can influence and support parents’ decisions and outcomes”, the authors wrote.
“This would provide robust evidence to support clinical practice, training and education of health care providers to improve outcomes for all families who experience the tragedy of stillbirth”.
– Amanda Bryan
1. MJA 2012; 197: 278-281
2. MJA 2012; 197: 256-257
3. MJA 2012; 197: 276
Posted 3 September 2012
Caring for families who have a stillborn baby requires a great deal of time and energy. The focus of care, for midwives in particular, is to meet the emotional needs of the woman and her family. As many stillbirths are unexplained, it is difficult to answer their questions. To discuss with a family who has just lost a baby, the potential benefits to others of allowing their baby to be subjected to an autopsy is also challenging at such an emotionally charged time. Perhaps an explanatory brochure could be devised to be left with the family to peruse when they feel able may assist them to make a decision.