What are the most effective interventions during pregnancy for preventing stillbirth?

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Antenatal interventions for preventing stillbirth, fetal loss and perinatal death: an overview of Cochrane systematic reviews

A stillbirth is generally defined as the death of a baby before birth, at or after 24 weeks of development. It is most common in low‐ and middle‐income countries but also affects people in high‐income countries. Numbers of stillbirths have not fallen much in the last 20 years and, despite the high numbers, it is not widely recognised as a global health problem.

This overview of Cochrane systematic reviews included 43 Cochrane reviews that assessed 61 different ways of preventing stillbirth during pregnancy, or infant deaths around the time of birth. However, few of these provided any clear evidence of an effect during pregnancy to reduce the risk of stillbirth or infant death. They were grouped into four different areas: nutrition, preventing infection, managing mothers' other healthcare problems, and looking after the baby before it is born.

Nutrition

  • Giving mothers balanced energy and protein supplements to increase the growth of the baby, particularly in undernourished pregnant women, probably reduces stillbirth by 40%.
  • For Vitamin A alone versus placebo (sham) or no treatment, and multiple micronutrients with iron and folic acid compared with iron with or without folic acid, there was clear evidence of no effect.

Prevention and management of infections

  • Insecticide‐treated anti‐malarial nets versus no nets may reduce loss of the baby in the womb (fetus) by 33%.

Prevention, detection and management of other healthcare problems

  • Where midwives were the primary healthcare provider, particularly for low‐risk pregnant women, loss of the fetus or infant deaths fell by 16%.
  • Having a trained traditional birth attendant versus having an untrained traditional birth attendant probably reduces stillbirth in rural populations of low‐ and middle‐income countries by 31% and infant death by 30%.
  • A reduced number of antenatal care visits probably results in an increase in infant death around the time of birth.
  • Community‐based intervention packages (including community‐support groups/women's groups, community mobilisation and home visits, or training traditional birth attendants who made home visits) may reduce stillbirth by 19%.

Checking the baby before birth

  • Cardiotocography measures the baby's heart rate and contractions in the womb. It can be recorded automatically by computer or manually, with pen and paper. Computerised cardiotocography to monitor baby’s well‐being in the womb, by measuring contractions, probably reduces the rate of infant deaths around the time of birth by 80% when compared with traditional cardiotocography.

The overview was uncertain about the effects of other methods.

Further high‐quality RCTs are needed to evaluate the effects of antenatal preventive interventions and which approaches are most effective to reduce the risk of stillbirth. Stillbirth (or fetal death), perinatal and neonatal death need to be reported separately in future RCTs of antenatal interventions to allow assessment of different interventions on these rare but important outcomes and they need to clearly define the target populations of women where the intervention is most likely to be of benefit.

Dr. Erika Ota, lead author and professor at the St. Luke’s International University in Japan says, “Stillbirth can be very upsetting for families and looking at what the evidence was across Cochrane systematic reviews was important to us. Cochrane systematic reviews provide high quality evidence. We assessed 43 Cochrane reviews with over 60 different ways to prevent stillbirth and infant deaths at birth.

We found that from these 60 different interventions, most interventions were unable to demonstrate a clear effect in reducing stillbirth or perinatal death. However, several interventions suggested a clear benefit to preventing still birth and infant deaths at birth, such as balanced energy/protein supplements, midwifeled models of care, training versus not training traditional birth attendants, and antenatal cardiotocography. Possible benefits were also observed for insecticidetreated antimalarial nets and communitybased intervention packages, whereas a reduced number of antenatal care visits were shown to be harmful.

The effectiveness of the methods used to prevent stillbirth varied depending on where they took place, highlighting that it is important to understand how they were tested. Unfortunately the findings cannot be applied to women in general and across all global settings but hope this overview will help show that further high-quality trials are needed in low- and middle income countries where a high burden of stillbirths occur.”

Wednesday, December 23, 2020
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