Over the past 25 years, one of the most significant achievements in human history is the dramatic decline in preventable child deaths, says the recent Millennium Development Goals report of the United Nations. But the report completely neglects the issue of stillbirth just like the World Health Organisation does in its study ‘Global Burdens of Disease’. The existing health policies and interventions at the global arena are mainly focused on the survival of newborn babies. 

In many countries stillbirth is still invisible—it does not find a place in public health priorities. It is one of the most ignored public health issues in politics and health investment. The problem of stillbirth exists in both developing and developed countries. However, due to the focus on high child mortality in developing countries like Nepal, preventing stillbirth is not a priority. 

Sheer numbers

Every year an estimated 2.6 million babies are stillborn, according to a report published in the medical journal Lancet. The overwhelming majority of 98 percent are born dead in low and middle income countries; over half of the stillbirths occur in rural regions of South Asia and Sub-Saharan Africa. The reasons are often found in bad health conditions of the mothers. Maternal obesity, infections and smoking are high risk factors, as is the inequitable access to obstetric and immediate postnatal care. Women from socially disadvantaged backgrounds have higher perinatal mortality rates than women from non-disadvantaged groups. 

One-third of stillborn babies have fetal growth restrictions, which means that they could not grow at the expected rate during pregnancy. Probably, they could not get enough oxygen and nutrition from the placenta or suffered from genetic diseases. Other causes of stillbirth are physical diseases and disorders or infections. But many of the causes of deaths are unidentified.

Nepal lacks authentic data to estimate these cases. This is due to few classification systems, laboratory investigation facilities and perinatal autopsies. Not surprisingly, laboratory investigation and verbal autopsy of stillborn babies are beyond our public health priority issues as our national health programmes are mainly focused on preventing child mortality.

However, a policy to improve  maternal and child health indirectly does target the issue of stillbirth. For example, antenatal care, folic acid supplementation and prevention of malaria help reduce the risks of stillbirth. Similarly, advanced antenatal care, which can detect high blood pressure and diabetes during pregnancy and fetal growth restriction, can also save the life of a fetus. Furthermore, skilled birth attendants, immediate care for neonates as well as basic and emergency obstetric care are also quite helpful. 

Possible Actions

Stillbirth is an important measure of the quality of maternity care and general health conditions of women. And some interventions can save the lives of unborn babies.

First is regular antenatal care. Early ultrasound helps determine fetal growth, which can identify the risk of fetal growth restriction and improve pregnancy outcome and maternal health. Second, maternal lifestyle is associated with the risk of stillbirths. Women with better education and employment have better maternal health outcomes than women from socially disadvantaged groups. Mothers can play a crucial role in spreading awareness. In mother groups, women can discuss preventable risks.  

Third, although determining cause is challenging due to the complexity of the situation, the investigation of stillbirth is crucial. Furthermore, stillbirth should be widely reported and publicised so that it is deemed a national health issue. This requires parental consent in verbal autopsy after stillbirth. However, getting parental consent in Nepal remains challenging due to complex religious and cultural reasons.  

Finally, communication and routine collection of data is to be given priority. Although routine data collection seems to be challenging due to complexity in definition and classification of stillbirths, the communication, advocacy and interaction in public forum can help prioritise the agenda of stillbirth. In fact, there is poor recording and reporting system due to the low priority accorded to the issue. 

To conclude, Nepal lacks proper recording and reporting of stillbirths, due to which estimating their number is often challenging. The national maternal and child health interventions have been focused on reducing preventable deaths. This has resulted in giving low priority to address the issue of stillbirth. Furthermore, the government and donor agencies have invested a lot in maternal and child health, while the budget allocation for preventing stillbirths is negligible. It is high time the government as well as NGOs/INGOs consolidated their interventions that can address the important issue of stillbirth. 

Khanal has a Masters in Public Health from The University of Melbourne