Review: The challenges of reducing risk factors for stillbirths

Source: The Lancet

The paper discusses the challenges surrounding the reduction of some long established risk factors for still births such as maternal overweight and obesity, smoking, high maternal age and primiparity.

The most common modifiable risk factor was maternal overweight and obesity while that for non-modifiable risk factors was primiparity.

Smoking reduction during pregnancy has been found to be a not so easy task.
In a study done amongst 25,000 pregnant women smokers in 64 countries divided into two groups (receivers of smoking interventions and non receivers) most of them in both groups continued to smoke during pregnancy.

The interventions however resulted in 6% more women quitting smoking during pregnancy with a 53 g increase in mean birth weight when compared with the control groups.

According to the paper reducing rates of overweight and obesity during pregnancy is an even greater challenge.
The biological pathway by which overweight and obesity affect stillbirth risk can only partly be explained
It is also unclear whether restriction of gestational weight gain is achievable in study settings.

There is also limited knowledge about bariatric surgery which could be an option for weight reduction, and can reduce rates of adverse maternal and neonatal outcomes.

The paper further alluded to the fact that recent trends in high-income countries, have had women delay childbearing for personal and professional reasons, which results in more women of older childbearing age, who may have infertility as a risk.

Can this trend be reversed by providing information on the risks involved with increased maternal age and making family raising and work more compatible?

As for smoking, the problems associated with overweight and obesity should benefit from receiving attention from communities, legislators, and politicians. 

Placental dysfunction disorders are also causal factors : stillbirth, pre-eclampsia, fetal growth restriction, and placental abruption.

These factors are closely linked and tend to recur in successive pregnancies, and may serve as predisposing factors to each other.

Ethnic and socio-economic stillbirth risks are unlikely to be explained by known risk factors for stillbirth. These risks may result from prenatal chronic stress or suboptimal quality of care, and other study designs are needed to help search for possible underlying mechanisms.

The writers agree with the school of thought that it is crucial to work at reducing the prevalence of risk factors for stillbirth and to increase pregnancy supervision in women with specific risk factors. 

They however conclude with an emphasis on the lack of effective tools to reduce the prevalence of many risk factors, particularly overweight and high maternal age.

Two-thirds of stillbirths happen in African rural settings, where skilled birth attendants, in particular midwives and physicians, are not always available for essential care during childbirth and for obstetric emergencies, including caesarean sections with Nigeria, Democratic Republic of Congo, Ethiopia and Tanzania topping the list. [2011]
In these places stillbirths often conveniently go unrecorded.

“Yet, stillbirth is a heartbreaking loss for women and families. We need to acknowledge these losses and do everything we can to prevent them.”says Flavia Bustreo, Assistant Director-General for Family and Community Health at the World Health Organization.[2011]