Stillbirth in a Tertiary Care Referral Hospital in North Bengal - A Review of Causes, Risk Factors and Prevention Strategies

Discussion:

Stillbirth is a traumatic experience for mother and obstetrician
alike. Stillbirth and perinatal mortality remains the index of ef-
ficacy of not only antenatal and intranatal care but also of the
socioeconomic condition of the entire community. Despite the
significant advances in fetomaternal medicine and economic
growth, stillbirth continues to be high, especially in the devel-
oping countries, contributing to 97% of 3.3 million stillbirths
reported worldwide annually.¹³

Stillbirth rates vary widely depending on geographic region, so-
cioeconomic condition and also in different regions in the same
country. While in developed nations stillbirth rate is 5 per 1000
or less, it is in the range of 30-40 per 1000 births in under-
developed countries.¹⁴

The average stillbirth rate in India as a whole is 39 per 1000
births¹⁵ with the reported stillbirth rate varying from 23 to
140.69/1000 births.^3,7-12,15 Underreporting of stillbirth is a com-
mon problem in our country.¹⁶ Also, the lower limit of gesta-
tional age or birth weight adopted in developed countries is 20
weeks, whereas in India, the cut-off gestational age is 28
weeks.

The stillbirth rate in our study, though well above the national
average of 39 per thousand, is comparable to
Chitrakumari(64.1),¹¹ less than Sujata(110)¹² but more than
Korde & Nayak(35.2) ³(Table 7)

The most striking finding of the study was the high rate of still-
birth (59.76 per 1000 birth) in a community where the women
were delivered in a tertiary care hospital by a doctor or a mid-
wife with an overall 16.2% caesarean section rate. Moreover,
more than 1/3^rd of the stillbirth was at term and another 20%
were late preterm (34-36 weeks). There were few (1.27%) con-
genital malformation and most were without maceration, indic-
ating that many of the stillbirths occurred in the peripartum
period and thus were salvageable during the time of labour and
delivery.¹⁶

Lawn et al¹³ noted that appropriate timing of caesarean section
should prevent many of the fetuses from dying during labour
and further suggest that many of these deaths would be avoided
with improved obstetric care and more rapid response to obstet-
rical complications.¹⁶

Thirty percent of women were registered in our study and 70%
were unregistered, whereas 84.9% were unregistered in study
by Korde & Nayak. ³ Stillbirth rate is 4 to 5 times higher among
unregistered women, which is also evident in other studies.^3,8,10

Socioeconomic status and literacy also influence pregnancy
outcome. In our study, 62% belonged to lower most socioeco-
nomic class with poor perinatal outcome, which is comparable
to the other.³

In developed countries, most of the stillbirths occur antenatal
and therefore frequently become macerated.

In our study and other studies from different developing coun-
tries, most stillbirths were fresh (59.72%), indicating that most
fetal deaths were peripartum. A population based study in rural
Pakistan with a stillbirth rate of 47/1000, 75% were fresh still-
births^17,18 which is similar to our study. The occurrence of an in-
trapartum stillbirth in developed country is considered the res-
ult of inadequate care²³ whereas in developing country it may
represent inadequate access to essential obstetric care and inad-
equate care.²⁴ The staggering high rate of stillbirths is also re-
lated to poor education, lack of awareness of available health
facilities, regular antenatal check-ups, early detection of preg-
nancy complications and proper monitoring by skilled provider
during labour and timed referral in higher centers. Stillbirth is
highest among the unregistered women (70.28%) which are
similar to other study.³ Among the mothers with stillbirth
nearly 30% were booked, 34.1% were at term and another 5%
were postterm and 16% of them underwent caesarean section.
Thus the findings from this study suggest that despite giving
birth in a health facility and having cesarean section rate even
higher than recommended for many developing countries, wo-
men may not have received appropriate obstetric care. ¹⁹ Many
women were referred late at a desperate, do or die situations
where limiting maternal deaths were more important than fetal
salvage. Therefore our study reinforces findings from other re-
cently published studies that report a failure of health facilities
to offer essential and comprehensive obstetric care.^17,19-21 Reas-
ons for this may be many, including inadequate number of
skilled providers, qualitative differences in the staff compet-
ence, delay in referral to higher health facilities to avail com-
prehensive obstetric care etc. Although 34.13% stillbirths were
term, preterm births also were significantly associated with
stillbirths similar to other studies.^17,22 In spite of the fact that
preterm births were significantly higher among stillbirths, term
or near term deliveries also were very high compared to the
western figures where 50% of the stillbirths occur at less than
28 weeks of gestation and 80% were preterm.¹⁶ This data sug-
gests that many of the peripartum stillbirths were potentially
salvageable during labour and delivery.

Thus it appears that suboptimal antepartum and intrapartum
service may be operating in our health system which contrib-
utes to a very high stillbirth and perinatal mortality rate. This
could be at various levels including primary, secondary and ter-
tiary. Patients themselves may contribute to suboptimal man-
agement of their own pregnancy. Seventy perecnt of our un-
booked cases contribute to suboptimal care by non-utilization
of antenatal services. Poverty, ignorance, illiteracy and poor
support from family especially from male members also re-
sponsible for inadequate care. Among the registered cases the
causes of poor outcome might be late registration and failure to
appreciate the significance of less fetal movement. Defaulted
follow-up and non-compliance of doctor’s advice were other
factors. Primary health care providers contribute to the subop-
timal care by failure to recognize the high risk cases. Poor mon-
itoring of labour, leading to late referral and not being able to
manage the emergency cases efficiently, including resuscitation
of asphyxiated babies, may be other factors responsible. Reas-
ons for this may be lack of obstetric skill, appliances and sup-
port.

Even at the tertiary level, the care may be the suboptimal, reas-
ons being overcrowding by too many serious high risk cases re-
ferred from periphery at late stage, disparity in the number of
patients and service providers and the service load etc.

Conclusions:

This study suggests that we have a long way to go to reach na-
tional goal of perinatal mortality of 30 per 1000 live births.
Many stillbirths in the present study seemed to be preventable.
A thorough up-gradation of health care delivery system in the
community is necessary. Although improvement of socioeco-
nomic condition, literacy and health education among women
will definitely be important to curb the staggeringly high still-
birth rate, but the need of the hour is to deploy adequate num-
ber of dedicated skilled providers with proper attitude for ser-
vice delivery. Importance of institutional delivery must be
stressed by health workers. There should be a widespread pro-

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