How common is stillbirth and how has this changed over time?
Stillbirth, the birth of a baby who shows no sign of life after 24 completed weeks of pregnancy, occurs in 1 in every 200 pregnancies in the United Kingdom. That’s roughly 10 bereaved families a day.
Over the last 20 years, the rate of stillbirth has barely decreased. We now rank 33rd out of 35 economically similar countries and our rate is approximately double that of Finland. I believe that this rate is unacceptably high.
What is known about the causes of stillbirth?
There are a wide range of causes of stillbirth, just as there are a wide range of causes for an adult to die.
The leading cause (about 40-50%) of stillbirth is a condition known as Fetal Growth Restriction, where a baby fails to grow to its potential. The majority of fetal growth restriction is caused by the placenta being unable to meet the oxygen and nutrient demands of the growing baby.
For me, understanding the placenta and how to assess its health and function is the key to reducing our stillbirth rate.
Can stillbirths be prevented?
About three quarters of babies who are stillborn were otherwise healthy (no lethal abnormalities) and had a weight of over 500g (the currently accepted birth weight that gives a good chance of survival). This suggests that if we had known that the baby was at increased risk of stillbirth, delivery would have been an option to save their life. The difficulty comes in knowing who is at risk.
Is there currently any way to identify vulnerable babies during pregnancy?
At the beginning of pregnancy, the midwifery and obstetric teams carry out detailed risk assessments to identify women whose babies may be at increased risk. Unfortunately this only identifies roughly 17% of the risk of stillbirth.
Throughout pregnancy the growth of the baby is monitored through measuring of the size of the womb to detect babies that are small or whose growth is static as this makes the baby more vulnerable. Once more, this only identifies about half of all small babies. However we know that 60-70% of mothers of babies who are subsequently stillborn notice a decrease in their baby’s movements in the hours or days prior to their death.
The Royal College of Obstetricians and Gynaecologists recommends that all women should be aware of their baby’s movements and should report any change. Whilst this is often a “normal” symptom in pregnancy (just as chest pain does not always mean a heart attack), this is something that should prompt further investigation and may help to identify vulnerable babies.
You have recently been awarded £133,955.00 by Action Medical Research in the form of a Research Training Fellowship to research stillbirth. How do you plan to use this funding?
The support provided by the children's charity Action Medical Research in the form of their Research Training Fellowship award is invaluable to my work. It is being used to fund me and the project team to study of 300 pregnancies where reduced fetal movements are reported by the mother. In these women we are developing tests to examine the size, structure and function of the placenta before birth, and examining whether these tests might be able to help us better identify babies at increased risk of stillbirth.
We are using standard two-dimensional and the newer three-dimensional ultrasound including Doppler studies (movement of blood) of the placenta, and placental hormone tests in mothers’ blood. These tests can then be taken forward into future studies, and eventually, into clinical care.
How will your study build on previous research?
We know that in stillbirth and fetal growth restriction the placenta (when examined after birth) is smaller, lighter and has poorer blood supply. There are also often lower placental hormone levels in the mother’s blood before the problems arise.
A recent study from our unit has demonstrated that the placenta in reduced fetal movement displays similar features, particularly in those pregnancies with subsequent poor outcome.
I believe that these differences in the placenta are visible before birth, and before the baby becomes overtly compromised and that they can be used as markers indicating the need for closer monitoring of the pregnancy.
What are the main aims of your research and what hurdles do you expect to face?
The main aim of the research is to develop accurate ways of assessing the placenta in the womb. We are looking at placental size, blood flow and hormone production. The main hurdle is, as always in clinical research, finding women willing to take part.
Beyond that, as the pregnancy develops it often becomes more difficult to examine the whole placenta due to the baby being “in the way” and the size of the placenta means that it might no longer “fit onto the screen”.
Once we have done this, we aim to take a preliminary look at which of these new tests are different between women who have normal and poor outcomes in pregnancy to see which have potential to identify babies at the highest risk of stillbirth.
What impact do you think your research will have?
By developing and validating methods to assess the placenta before birth and identifying candidate measurements that appear to predict a risk of poor outcome in pregnancy, this will enable researchers to test the predictive power of placental measurements in pregnancy risk assessment.
How do you think the future of stillbirth research will develop?
I believe the placenta is the key to understanding the causes and prevention of stillbirth. At the moment, the only question asked of the placenta before birth is “where is it? Is it going to block the birth canal?”. If the answer is “no”, then we leave it be.
In the future I think that we will move towards asking the question “will this placenta support the baby throughout pregnancy?”. Hopefully my work will provide tools to start answering this question.
What first prompted you to research stillbirth?
I am a trainee doctor in Obstetrics and Gynaecology. Generally my working environment is a very happy one, I feel very privileged to be involved in caring for mothers and their babies through pregnancy and to help deliver these babies into their families.
When this goes wrong, when a baby dies before birth, it is devastating for all involved and everyone wishes that there was something they could have done. But no one seems to talk about this, about how often it happens, about how no progress is being made in stopping it happening. If I can help to stop that happening to even one less family, then it will be a job well done.
Where can readers find more information?
Action Medical Research is a UK-wide charity saving and changing children’s lives through medical research. It wants to make a difference in:
- tackling premature birth and treating sick and vulnerable babies
- helping children affected by disability, disabling conditions and infections
- targeting rare diseases that together severely affect many forgotten children.
The charity runs a Research Training Fellowship scheme. This supports promising doctors and researchers early in their careers and develops future leaders in children’s research. As Research Training Fellows, these high-fliers carry out a key piece of research to help children and undertake training to develop their research expertise. Over the past 40 years, Action Medical Research has funded 164 fellowships at a total value of over £11 million (almost £17 million in today’s terms).
More information on my Fellowship at:
http://www.action.org.uk/our_research/research_training_fellowship_dr_lucy_e_higgins
Tommy’s the Baby Charity funds research into pregnancy complications, including funding a dedicated stillbirth research centre at the University of Manchester. A dedicated section of their website, www.tommys.org, talks about research into all aspects of stillbirth.
The Stillbirth and Neonatal Death Charity (SANDS) is a UK-based charity that provides support for bereaved parents and families and works to raise the profile of stillbirth on the political agenda. They also work with researchers to understand the causes of stillbirth, its prevention and the best care that can be provided for those affected. Their website, https://www.sands.org.uk/, provides a wealth of information about stillbirth and contact information for those seeking support and further information.
For those looking for a heavier read, the Lancet stillbirth series provides a sobering collection of articles discussing the global problem of stillbirth and how experts recommend we should try to address the issue, you can read summaries of these articles here: www.thelancet.com/series/stillbirth.
And finally, for expectant mothers (and those around them), the Royal College of Obstetricians and Gynaecologists has provided two particularly relevant patient information leaflets which can be downloaded online: “Your baby’s movements in pregnancy: information for you” (www.rcog.org.uk/womens-health/clinical-guidance/your-babys-movements-pregnancy) and “When your baby dies before birth” (www.rcog.org.uk/womens-health/clinical-guidance/when-your-baby-dies-birth-information-you).
About Dr Lucy Higgins
I graduated from the University of Birmingham in 2006 with MBChB (hons) and followed a combined clinical academic career path since then.
In 2008 I moved to Manchester to work in the Maternal and Fetal Health Research Centre, University of Manchester alongside clinical training in Obstetrics and Gynaecology. I became a member of the Royal College of Obstetricians and Gynaecologists in November 2011, winning the gold medal in my membership examinations.
I am currently taking time out from my clinical training to complete a PhD funded by an Action Medical Research research training fellowship. My career goal is to become a leading clinical academic in the field of high risk obstetrics with a particular focus on stillbirth prevention.
New research could lead to earlier diagnosis and better management of inflammatory bowel disease