Every day in the 40 weeks that a mother bears a baby in her womb is a lifetime. A mother’s body goes through numerous psychological, emotional, and physical changes while she is raising a life within her.
To imagine that approximately 2,000 expecting mothers’ hopes are shattered each day because of a lack of access to basic health care facilities seems impossible in the 21st century.
Stillbirths are defined as the death of the infant in the womb after the first 28 weeks of pregnancy. But stillbirths are not a stand-alone problem with a single solution. They are a part of a larger constellation of issues such as maternal mortality, infant mortality, malnourishment in children under 5 years old, anemia in adolescent girls and expecting mothers, and so on.
Where do stillbirths occur?
According to a study published in the Lancet in 2011, around 1.8 million stillbirths occur in a handful of ten countries of the world. Half of those 1.8 million stillbirths occur in India, Pakistan, Nigeria, China, and Bangladesh. A woman in the African subcontinent has up to 24% higher likelihood of having a stillborn child than a woman from a country with a higher income.
A similar picture is painted when we look at the state-wise statistics of India alone. The rates vary widely by state within India itself, with a difference of 4.6 to 24.5 stillbirths per 1,000 live births. More than two-thirds of stillbirths happen in rural areas where there is a lack of skilled birth attendants and nearby centers for good quality obstetric care.
It is important to note that stillbirth data is prone to underreporting. Stillbirths have such a deep psychological impact on the minds of parents that they rarely get reported. Besides, stillbirths mainly happen in remote areas with a lack of reporting facilities. Furthermore, the taboo associated with this phenomenon makes underreporting even more likely. An accurate and foolproof reporting system must be the first step towards addressing the stillbirth problem. The Mother and Child Tracking system, which is discussed in detail later, is an initiative in this direction.
The causes and risk factors for stillbirths
Accessibility has the most direct, deep impact on these numbers. Accessibility — in terms of distance and availability to health care services during, before, and after childbirth — is of foremost importance. However, accessibility to other resources such as employment, education, and commodities are just as important. Moreover, accessibility to knowledge and information play a vital role in encouraging better health and child care choices.
The association between stillbirths and other mother and child health outcomes is also clear if we look at the data. The same handful of countries that have the highest number of stillbirths also have the highest maternal mortality rates, as well as infant and neonatal death rates.
There are five main causes of stillbirths:
- Childbirth complications
- Maternal infections during pregnancy
- Maternal disorders (especially pre-eclampsia and diabetes)
- Fetal growth restriction
- Congenital abnormalities
Most of these complications can be avoided by providing good quality obstetric care. The lack of even basic, low-cost medical technology for use during labor leads to high maternal mortality rates.
The complications can also be addressed through prenatal screening and guidance programs that adhere to Indian government guidelines. However, these programs are not properly implemented because of Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs), and Anganwadi Workers (AWWs) are not held accountable for the programs. In addition, improper staffing at Primary Health Centers (PHCs) and inadequate health facilities for the urban poor further lead to poor prenatal screening and guidance programs.
What seems to be working?
The state-wise data shows that stillbirths, neonatal mortality, and maternal mortality rates have a close link with each other, so it is likely that what has worked for one issue might also work for the others.
A study conducted in Jharkhand and Orissa randomly stratified over 200,000 low-income women into intervention and control groups. A facilitator convened 13 groups every month to support participatory action and learning for young mothers. The facilitator also developed and implemented strategies to address maternal and newborn health problems. The study showed significant improvements in maternal and neonatal outcomes over the next three years. This study went ahead to suggest policy changes in the current health-worker-based individual intervention strategies.
Similarly, in Dahanu, the stillbirth rate dropped from 18.6% to 9% over a three-year period. This change followed the introduction of a traditional birth attendant training program in which neonatal resuscitation was given the highest importance.
Studies like the two above indicate that, if they are implemented diligently, focused interventions using existing solutions can quickly change health outcomes.
In an attempt to leverage technology in infant and neonatal mortality, the Ministry of Health and Family Welfare and National Informatics Centre have jointly developed a system called the Mother and Child Tracking System (MCTS). MCTS was was launched by the Government of India in December 2009 in collaboration with states and UTs.
This system aims at tracking all pregnant and lactating mothers from the baby’s conception to the 42nd day after childbirth. In addition, the system follows up on all children under 5 years old. Each health service provider enters information about the mother’s status, any tests performed, and details of the pregnancy into the system. Then, during the pregnancy, mothers receive messages or calls with useful information about maternal health and child care.
This system is an important step forward in the government’s use of technology at the grassroots level. More importantly, this data will help identify patterns of problems, which can lead to the creation of workable solutions or interventions by ANMs or ASHAs.
The road ahead
Such novel innovations might be crucial for progress in the health outcomes but they are not enough by themselves. Tackling stillbirths and improving the health of the mother and the child requires a collective effort from various sectors. Without roads and effective transportation, scaling health infrastructure is not enough. Promoting institutional deliveries without ensuring quality services at PHCs is a task half done. Increasing PHC facilities without luring doctors to remote areas is futile. Expecting AWWs and ASHAs to work with without good compensation is not practical. Lastly, poverty, deprivation, and a lack of financial security will always keep women from the healthy lifestyle and eating habits that lead to better maternal health.
Unless larger societal issues are also addressed, ensuring the unborn child’s health will remain an unachievable target.
High stillbirth, maternal mortality, and neonatal mortality rates are unacceptable in 2015 — a time when more than half of the world’s countries have long since addressed these issues. It is mandatory for both policy makers and implementers to work towards improving mother and child health and reducing stillbirths.