There are nearly two million stillbirths every year. Credit: UNSPLASH/Claudia Wolff

By Samira Sadeque
UNITED NATIONS, Oct 26 2020 (IPS)

Societal taboo and a lack of understanding about stillbirth  can cause the issue to be neglected among health practitioners, according to Dr. Danzhen You, a senior adviser on Data and Analytics at the United Nations Children’s Fund (UNICEF).

She shared her insight with IPS after a U.N. high-level meeting organised to raise awareness and to end preventable stillbirths last week.

There are nearly two million stillbirths every year, according to a joint statement released ahead of the event by UNICEF, the World Health Organisation (WHO), and the World Bank Group and the Population Division of the U.N. Department of Economic and Social Affairs.

At the talk, WHO Director General Dr. Tedros Adhanom Ghebreyesus called for an end to the stigma surrounding stillbirths and for higher investments to prevent them. In the last 20 years, he said, 14 countries, including Cambodia, India and Mongolia have been able to reduce their stillbirth rate by more than half.

But this growth regressed because of the coronavirus pandemic.

With reference to the mothers who suffer from stillbirth, he said: “They need support, not shame.”

Christine Wangechi from Kenya, who suffered a stillbirth last year, said during her trauma, she was not aware that there are other women who had similar experiences.

She said her experience was very “silent” and that she hopes that in speaking publicly, she can help other grieving mothers feel less alone.

Istiyani Purbaabsari, a midwife from Indonesia who spoke at the event, also added that a lack of awareness may be impeding the progress on lowering stillbirths.

The stigma, combined with the lack of awareness or communication about the issue, means it remains left out of conversations, according to You of UNICEF, who is also the Coordinator of the U.N. Inter-agency Group for Child Mortality Estimation.

Excerpts of the interview with You follow:

Inter Press Service (IPS): According to UNICEF, the issue of stillbirths remains low as a priority on the global public health agenda. Why has it not been a priority in these conversations?

Dr. Danzhen You (DY): With two million babies stillborn every year, the burden of stillbirths is enormous. They are invisible in policies and programmes and under-financed as an area requiring intervention.

Most people (including some clinicians) do not have a common understanding of what a stillbirth is; definitions vary across and within countries and cultures. The death of an unborn baby remains a taboo topic in many cultures. Communications work has been insufficient in raising awareness among communities, health professionals, and policy makers about the burden of stillbirth, including numbers, preventability, and the pain and grief it causes to women and families

There is also a lack of understanding of stillbirths, leading to fatalism, guilt and blame. Many clinicians are not aware that most stillbirths are preventable with known interventions; many families and communities also do not realise this, meaning it is often the woman who is blamed or feels responsible for the loss.

IPS: How do the stigma and misconceptions surrounding stillbirth hamper the efforts to end stillbirths?

DY: Stillbirths are often regarded as inevitable events and may be grouped with miscarriages for reporting. In some cultures, stillbirths are perceived as the mother’s fault, resulting in public shaming or individual feelings of guilt or shame that prevent public mourning of their loss.

Moreover, the lack of opportunity to publicly grieve can cause stillbirths to be considered “non-events”. In some countries, stillbirths are perceived as rare, accounting for a negligible fraction of the burden of disease in countries or at global level.

These social taboos, stigmas and misconceptions often silence families or impact the recognition and grieving of stillbirths, contributing to their continuing invisibility.

IPS: How has the coronavirus pandemic affected the issue of stillbirths?

DY: The world is currently scrambling to understand how the COVID-19 pandemic might be leading to disruptions in health services. Our analysis shows that the response to the pandemic could worsen the situation by potentially adding nearly 200,000 stillbirths to the global tally over a 12-month period in 117 low and middle-income countries in a scenario with severe health service disruptions (around 50 percent) due to the COVID-19 pandemic. This number may underestimate the additional stillbirth burden that could occur.

However, we were missing opportunities to prevent families from experiencing the pain of stillbirths even before the pandemic. Few women received timely and high-quality care to prevent stillbirths. In half of the 117 low and middle-income countries analysed, less than two to 50 percent of pregnant women received key interventions that could prevent stillbirths. For example, coverage for assisted vaginal delivery – a critical intervention for preventing intrapartum stillbirths – is estimated to reach less than half of pregnant women in low-and middle-income countries.

IPS: What are some challenges that remain with  gathering statistics on the issue?

DY: The targets specific to stillbirths were absent from the Millennium Development Goals (MDGs) and are still missing in the 2030 Agenda for Sustainable Development. Many countries do not have a defined stillbirth target. Among the 93 countries that have reported on their progress using the Every Newborn Action Plan tracking tool, only 30 have a defined stillbirth target, compared to 78 countries with a neonatal mortality target.

Stillbirths are largely absent in worldwide data tracking, rendering the true extent of the problem hidden. Sixty two countries had either no stillbirth data or insufficient quality data. While the causes of neonatal death are tracked globally by WHO, there are no such data for stillbirth.

IPS: What do you think is the way ahead?

DY: Progress is possible with sound policy, investment and programmes. For example, Southern Asia, which has the second highest stillbirth rate of all regions in the world, has reduced the stillbirth rate by 44 percent since 2000.

We must do better, faster, or 20 million babies will be stillborn by 2030. There is hope, but only if we act now, collectively, by raising voices, increasing awareness, reducing stigma, taboo and misconception.

Delegates to this week’s annual meeting of the World Health Assembly (WHA) in Geneva should agree on an ambitious agenda to sharply cut the rate of newborn deaths and stillbirths over the next two decades, according to maternal and infant health experts.

Reducing the rates of newborn deaths and stillbirths has lagged significantly behind the remarkable progress achieved in cutting mortality among children between the ages of one month and five years, according to a new study in the “Every Newborn” Series published by the British medical publication, ‘The Lancet”.

Thanks in major part to the U.N.’s Millennium Development Goals (MDGs), reductions in mortality for children 1-59 months and maternal mortality have averaged 3.4 percent and 2.6 percent annually, respectively, in recent years. By contrast, the neo-natal mortality and stillbirth rates fell by only two percent and around one percent per year, respectively.

Breast milk is vital for a premature newborn weighing barely 500 grams.
Credit: Manipadma Jena/IPS

That lag has been caused above all by “disappointing levels of investment in newborn health,” according to the study, which drew on the work of more than 55 experts from 29 institutions in 18 countries.

“So far, investment targeted to newborn health has been miniscule,” noted Joy Lawn of the London School of Hygiene & Tropical Medicine, who led the research on which the study is based along with Zulfiqar Bhutta from the Hospital for Sick Children in Canada and the Aga Khan University in Pakistan.

“Nearly half (44 percent) of all deaths in children under five are in the first month of life, yet only four percent of donor funding to child health even mentions the word newborn,” Lawn told IPS.

Indeed, every year, some 2.9 million infants die within 28 days of their birth, and another 2.6 million die in the last three months of pregnancy or during childbirth, according to U.N. estimates. Nearly half of these deaths occur during labour.

Many of those stillbirths have remained invisible, however, on the global health agenda, because nearly all of them go unreported to health authorities, and data collection on both stillbirths and neo-natal deaths is in any case inadequate. This is particularly true in the most-affected countries which include India, Pakistan, Afghanistan and Bangladesh, as well as Nigeria and a number of other sub-Saharan countries, according to the study. More than 75 percent of newborn deaths occur in South Asia and sub-Saharan Africa.

This week’s meeting of the WHA, the governing body of the World Health Organisation (WHO), will take up the “Every Newborn Action Plan” (ENAP) aimed at encouraging donors and beneficiary countries to accelerate action aimed at addressing the problem.

“The plan is based on a series of measures that are already proving effective in keeping women and children healthy – from preconception and pregnancy through to childhood and adolescence,” according to Dr. Elizabeth Mason, irector of WHO’s Department for Maternal, Newborn, Child and Adolescent Health. “Our goal is to end preventable newborn deaths within a generation.”

Specifically, the plan envisages reducing national neo-natal mortality to fewer than ten deaths per 1,000 live births and stillbirth rates to fewer than ten per 1,000 by 2035, resulting in global averages of seven and eight, respectively, according to the report.

If successful, that would cut current rates of neo-natal mortality and stillbirths by more than half and by as much as 85 percent in the worst-affected nations.

The study identifies proven interventions, including the promotion of breastfeeding; neo-natal resuscitation; so-called kangaroo mother care, which involves holding pre-term infants close to the mother’s skin for warmth and regulating their heartbeat; and providing corticosteroids that prevent infection resulting from cutting the umbilical cord.

The implementation of these interventions by themselves “could get newborn deaths down substantially in the first couple of years,” Melinda Gates, co-chair of the Bill and Melinda Gates Foundation, the world’s largest private source of funding for global health initiatives, told the ‘Wall Street Journal’ in an interview published Monday.

She is scheduled to address the WHA in support of ENAP Tuesday. Along with the U.N. Children’s Fund (UNICEF), WHO, and various bilateral agencies, the Gates Foundation is expected to be a major source of funding for the plan.

Lawn stressed the importance of having trained personnel available during and immediately after birth. “A critical issue is the need for more midwives and nurses with skills to look after women in labour and small and sick newborns,” she told IPS in an email. Each year, one million babies die on the day of their birth, according to the report.

Indeed, the most common barriers to improving survival rates were related to the dearth of trained health workers, according to studies of eight of the worst-affected countries – Afghanistan, Bangladesh, Democratic Republic of Congo, India, Kenya, Nigeria, Pakistan, and Uganda.

The study found that those countries that have achieved the most rapid reductions in maternal and newborn mortality – such as Malawi, Nepal, and Peru – have done so in major part by expanding their health workforce, improving care for small and sick newborns, and implementing new programmes designed to reach the poorest families.

Along with trained personnel, the availability of healthcare facilities is also critical.

“The increasing number of women who are giving birth at healthcare facilities presents the most immediate opportunity for action,” according to Bhutta.

“Our analysis shows that by increasing facility births and closing the quality gap at healthcare facilities by 2020, we could prevent an estimated 113,000 maternal deaths, 531,000 stillbirths, and 1,325 million newborn deaths each year. This should clearly be an immediate priority,” she added.

Lily Kak, the senior advisor for Global Partnerships and Newborn Health at the U.S. Agency for International Development (USAID), praised ENAP, calling its introduction a “historic moment and opportunity” and noting that it is “the first plan to unite the global community around progress toward newborn health outcomes.”

“Although we have seen incredible success in bringing down under-5 deaths, neo-natal mortality rates have declined at a slower pace,” she told IPS in an email. “This is in part because newborn health was not a global priority, investments were minimal, and simple and cost-effective ways of tackling the leading causes of newborn mortality—prematurity, asphyxia and sepsis— are better understood now.”

About 99 percent of patients with obstetric fistula cannot afford to pay their doctors. Credit: Jugran Bahuguna/IPS

By Zofeen Ebrahim
KARACHI, May 27 2013 (IPS)

Sherhshah Syed is a highly qualified doctor and president of the prestigious Pakistan National Forum on Women’s Health (PNFWH) but his income does not match his qualifications.

He often spends long hours treating women with obstetric fistula, a severe reproductive health condition arising during childbirth that primarily affects women and girls who have no access to even the most basic medical care.

But since fistula is considered to be “the poor woman’s” disease, few of his patients can afford to pay him for his labour.

Dr. Sajjid Ahmed, who heads a PNFWH fistula project, tells IPS with a smile, “More than 99.9 percent of (our) patients are so poor, all they can offer us in exchange for giving them a new life is gratitude and an embroidered handkerchief.”

Labelled an “entirely preventable condition” by the international medical community, fistula develops during prolonged labour, “when the baby’s head puts pressure on the lining of the birth canal and eventually (rips) through the wall of the rectum and bladder, resulting in urinary or faecal incontinence,” Syed told IPS.

Fistula also causes stillbirths, kidney failure and a perpetual faecal odour emanating from the woman’s body.

The condition is rarely found in the developed world but is common in many Asian and African countries, affecting an estimated three million women, according to the World Health Organisation (WHO).

The fact that there are no country-specific statistics available for Pakistan is indicative of the indifference and stigma that surrounds the ailment.

Syed made a “conservative” guess that anywhere between 5,000 and 6,000 women in Pakistan are suffering from the condition, which can only be treated through reconstructive surgery.

“While we are able to (treat) 1,000 women each year, there are many more who suffer silently,” he said, attributing this silence to a sense of shame, a culture that does not allow women to make decisions about their own bodies and a lack of awareness among health practitioners.

Some experts blame this on flaws in medical colleges’ curricula. Dr. Qazi M. Wasiq, general secretary of the Sindh chapter of the Pakistan Medical Association (PMA), says colleges are “out of touch” with the needs of the country and the community.

“We train our young doctors to serve in countries like the United States, the United Kingdom and the Middle East, where fistula is non-existent. Most students have only a bookish knowledge of the condition, with hardly (any awareness) of the debilitating details.”

This oversight has heavy ramifications in Pakistan, a hotbed of maternal and infant mortality. According to official statistics in the Pakistan Demographic and Health Survey of 2007, the last time such data were gathered, the maternal mortality rate (MMR) of 276 per 100,000 live births is one of the highest in the region.

In comparison, according to the WHO, the MMR is 35 in Sri Lanka, 170 in Nepal, 200 in India and 240 in Bangladesh. Many other countries in South Asia are showing signs of progress, but Pakistan’s MMR has remained virtually unchanged since 1991.

In addition, the infant mortality rate is 78 deaths per 1,000 live births; for those under five the rate is even higher, touching 94 deaths per 1,000 live births. This means one in every 11 children born in Pakistan dies before reaching his or her fifth birthday.

The vast majority of these fatalities occur in the countryside, where women have little or no access to basic care. Most qualified female gynaecologists are reluctant to take up posts in remote rural areas, particularly in provinces like Balochistan and the northwestern Khyber Pakhtunkhwa (KP), according to PMA’s Wasiq.

According a recent report by the British medical journal ‘The Lancet’, evidence-based interventions can prevent roughly 58 percent of an estimated 368,000 deaths of mothers, newborn babies and children. In addition, 49 percent of an estimated 180,000 stillbirths could be prevented by 2015.

For years, Syed and his colleagues have urged the government to invest in providing basic emergency obstetric care by deploying trained birth attendants into rural areas to advise families against early child marriage, one of the leading causes of fistula.

According to Syed, dispatching an additional 400,000 nurses, paramedics and midwives to some 80,000 villages across Pakistan would have a huge impact on maternal mortality rates.  So far, however, there only 148 schools training 28,000 midwives.

With no official monitoring of the situation, women who develop conditions like fistula have to rely on concerned relatives to take action on their condition.

Ahmed says it is always mothers, fathers and brothers who accompany fistula patients to treatment centres – rarely, if ever, do husbands or in-laws volunteer to deal with the condition.

In 2006, the PNFWH in collaboration with the United Nations Population Fund (UNFPA) started the Fistula Prevention and Treatment Project with the aim of providing free treatment services to fistula patients all over the country, and training service providers.

On May 23, the UNFPA marked the first-ever International Day to End Obstetric Fistula, with the aim of building on local efforts to raise awareness of a condition that is not “understood even in societies where it is prevalent.”

In the eight years since the UNFPA project began, 13 fistula repair centres have been set up across Pakistan, all in government hospitals; but trained doctors, who currently number about three dozen, have not increased proportionately.

Ahmed says building an adequate medical force to deal with the problem requires commitment, compassion and sensitivity without the expectation of anything in return.

“Then again,” said Syed, “not everyone is mad enough to spend hours on something that earns you prayers but no economic benefits.”

Medical practitioners tell IPS that an obstetrician’s salary in a government hospital is anywhere from 600 to 1,000 dollars per month. In comparison, those with private practices earn the same by performing just one caesarian section.