Decreasing Stillbirths

I have written often here on Substack and on KevinMD about the high U.S. maternal mortality rate (32.9 per 100,000 births). ProPublica produces many good stories about maternal mortality. So when I recently saw a ProPublica article praising Australia for their efforts to reduce the stillbirth rate, I was curious about Australia’s program. ProPublica says:

“Australia has emerged as a global leader in an effort to lower the number of babies who die before taking their first breaths….It’s an approach that could benefit America, which lags behind other wealthy nations in reducing stillbirths.”

ProPublica reports that since 2017, the Australian government has invested more than $40 million in developing a national stillbirth reduction plan. In contrast, according to UNICEF, between 2000 and 2021, the U.S. ranked below 151 countries in reducing the stillbirth rate. Each day in the U.S., there are 60 stillborn babies, or more than 20,000 stillbirths each year.

These numbers put the U.S. on a par with African South Sudan and Asian Turkmenistan.

What is Australia doing? They have what they call a “Safer Baby Bundle.” Specifically, this includes five “evidenced-based” priorities:

1. Support to stop smoking.

2. Monitoring for signs of a too-small baby.

3. Looking for signs of decreased fetal movement.

4. Sleeping on your side after 28 weeks.

5. Talk to your doctor about when to deliver.   

While I commend the people of Australia and their leaders for committing to a national campaign to decrease stillbirths, many of the recommendation are much like the kinds of suggestions made in U.S. programs to reduce maternal mortalities. I see many of the problems with unsuccessful U.S. programs for reducing maternal mortalities in the Australian “Safer Baby Bundle.”

Support to Stop Smoking

This is blaming the patient for the problem. Certainly a physician should recommend giving up smoking. I have often suggested to my smoking patients that they reduce their cigarettes to one a day. If they do reduce their smoking, that’s great. But if they do not, we shouldn’t blame them for contributing to stillbirths.

There are many other causes of stillbirths. These five suggestions are mostly something that patients are supposed to be doing, and to me there’s a lot of gaslighting here, in other words, blaming patients for their illness. Naturally, we should recomment the patients stop smoking and the providers advising them to stop smoking. So, this is rather a “no brainer.”

The Problem with Evidence-Based Medicine

The five priorities listed in the “Safer Baby Bundle” are denoted to be “evidence-based.” In medicine, this moniker has come to be attached to any medical description as somehow making whatever topic is on the table gold-plated. In medicine, we are supposed to say these words if we want to sound erudite and informed. In reality, much of good medical practice lies outside the evidence-based check list.

Looking for Signs of Decreased Fetal Movement

The real topic here should be dismissiveness of patient concerns. In other articles, ProPublica has given us several examples of dismissiveness with patients’ fetal movement concerns. In other words, the provider feels that the patients’ complaintx are unjustified and that the patients really have nothing wrong with them. So the patients are sent back home.

ProPublica has recently given two examples of patients who presented to the hospital with concerns about decreased fetal movement. One was told to go home on three separate occasions. The other was told to go home twice. In both cases, the charts indicate the nurses dismissed the patients’ concerns because the patients really “didn’t know” how to monitor the baby. Both patients returned two or three more times concerned about the lack of movement with their babies, only to be told there was nothing wrong and to return home. The final time these patients returned, their babies were dead. Both patients were told by the doctor that they should’ve come in earlier, adding insult to injury.

What’s the point in teaching moms how to monitor fetal movement if their concerns are dismissed by nurses or providers? No woman’s concerns about fetal movement should be dismissed without being seen by a doctor, preferably her own doctor. 

Dismissiveness is a problem which cuts across all of healthcare, including doctors and nurses. We all need to take a look at dismissiveness as a problem and we need to plan to deal with it effectively.

Stillbirths and Repeated Stillbirths

The Australian article talks about preventing stillbirths, but the subject of repeated stillbirths isn’t mentioned. Repeated stillbirths are another serious problem which isn’t being addressed. It seems to me to be reasonable to look for infection as a cause of preterm birth as well as stillbirth. When I tested my patients, I naturally wanted to assess for the usual and more common infections such as gonorrhea and chlamydia. I actually never found gonorrhea in my patients. Chlamydia was seldom found, but to my surprise, I found a lot of ureaplasma and mycoplasma. At that time these organisms were considered to be non-pathogenic, that is not harmful. Today we have articles indicating that they are pathogenic and also very much part of male infertility.

But 40 years ago, we didn’t have that information. It did occur to me that if the mother had ureaplasma or mycoplasma that the father likely also carried these organisms, so I treated both the mother and father. This was successful as far as preventing preterm birth and stillbirth so it occurred to me that there might be other infectious causes as well.

We were told for a long time ago that Strep B didn’t matter and we should neither test for nor treat it. That bothered me, so I developed my own treatment long before the Centers for Disease Control and Prevention (CDC) decided to create their protocol. Strep B has commonly been considered not to be an ascending infection.  In other words, it was considered to be a vaginal infection only, with the baby exposed to Strep B only after rupture of membranes and  a vaginal delivery.

I never actually saw any babies sick with Strep B except for a referral for a repeat
C-section. There was no labor and there were no ruptured membranes. The baby was sick with Strep B. Thank goodness I worked with a very good neonatologist who treated the baby quickly and vigorously, and there were no problems.

In my experience, stillbirth and recurrent stillbirth can be treated by the five points of the Australian “Safer Baby Bundle,” but there is far more to preventing stillbirths than these five points. The solutions I’ve suggested  here are actually quite simple and inexpensive and could be exported to other countries as well.

As an example, years ago a young couple came to my office with a problem of complete infertility. They had been unable to become pregnant. They taught English as a second language in many countries on various continents and had had in vitro treatment on several continents. They gave me 10 days to do what no one had done before. I checked both of them for ureaplasma, mycoplasma and other infections. As it turns out, they had ureaplasma. I treated them both with doxycycline, 100 mg twice a day for 10 days. Then they went off to teach English in Japan. Three months later I got a phone call. They were pregnant. Six months after the first phone call I got a second phone call. They had a healthy newborn 8-pound baby girl born at term. My $200 treatment succeeded when several $30,000 treatments had failed.

Tightening the Ship

The Australian recommendations cited by ProPublica contribute to reducing stillbirths. The recommendation that fetal heart rate receives immediate attention is a good one, but I believe there should also be a recommendation to test for and treat the organisms we now know cause miscarriage and stillbirth.  Plus, with dismissiveness such a problem in healthcare today, is anyone actually checking on how quickly women reporting less fetal movement are seen and treated as opposed to being sent home without seeing a doctor? I strongly suspect if dismissiveness were effectively removed from the care of pregnant women, stillbirths would decline markedly. The “evidence-based” recommendation is an important one, but is the recommendation being followed? I’d like to see some numbers.