ANGUISH OF THE STILLBIRTH DILEMMA
It’s an agonising decision so many pregnant women face: should you risk being induced before 42 weeks — after which the chances of a stillbirth rise? Now, a dramatic proposal from NICE could save infant lives
Had alex Barr’s daughter Marnie been born a day earlier, she would — in all likelihood — still be alive. alex, 33, a nurse, was almost two weeks over her estimated due date when her husband Steve drove her to the maternity unit to be checked in april last year.
The pregnancy had already been an anxious one. alex had the extreme morning sickness disorder hyperemesis gravidarum throughout, and then there were concerns that Marnie’s growth had slowed down in the third trimester, which led to extra scans.
It was at one of these appointments, in the week of her due date, that alex first asked if she could be induced.
Instead she was told there was no reason she couldn’t have a ‘normal’ birth.
a week later — and a week overdue — alex asked for a sweep (where a midwife manually attempts to separate the pregnancy sac from the cervix to bring on labour), but this was declined due to the risk of Covid.
Instead, alex was booked in for an induction five days later, at 42 weeks — 12 days after her due date.
But the morning before her induction, alex started to leak fluid and went to hospital. Her waters broke in the maternity unit. But after being monitored for 20 minutes, she was given the all-clear to go home to wait for contractions to start — even after she saw some bright-red blood on her pad. The midwife said it was probably just her ‘show’ (the plug of mucus that comes away at the start of labour, sometimes tinged with blood).
By THE time alex got home 30 minutes later, with Steve, 37, an account manager, and their son, ashton, four, she was bleeding ‘profusely’ and was blue-lighted back to the hospital. There she was told that Marnie no longer had a heartbeat — the placenta had failed, causing a massive haemorrhage. Marnie was stillborn.
‘There are no words to describe it,’ says alex. ‘I let out the most awful, animalsounding noise. I couldn’t believe it when I’d been there less than two hours before and she’d been alive.’
In the weeks that followed, ‘I was completely numb’, recalls alex, who lives in dorset. ‘you’re ready to have this baby and then there is no baby.’
In the UK, around one in 250 babies is stillborn (defined as a baby who dies during pregnancy after 24 weeks). despite some improvement to the stillbirth rate in the past decade, we still rank behind many other developed nations, including the Netherlands, Canada, Italy, and Singapore.
In the hope of preventing more stories like alex’s, the National Institute for Health and Care Excellence (NICE) recently recommended all women should be offered an induction by 41 weeks of pregnancy — a week overdue. This is one week earlier than current guidance.
The draft guidance, published in May, is based on evidence from studies showing that inducing more women earlier could prevent stillbirth and reduce the need for intensive care treatment after birth. It also reduces the risk of women dying during childbirth.
However there are concerns that, if adopted, it could lead to more women being pressured into inductions they do not want, may not need, and that the health service may not be equipped to deal with. So many women and healthcare professionals spoke out against the proposals.
It is clear performing more inductions is far from a silver bullet for improving the UK’s stillbirth rate.
The number of stillbirths the proposed change could prevent is likely to be ‘very small’, says asma Khalil, a professor of obstetrics and maternal-fetal medicine at St George’s University Hospital, London, as most women will have given birth before 41 weeks.
The latest data shows that 89,699 women delivered at 41 weeks in 2019, with 12,705 delivering at 42 weeks or beyond. There were 92 stillborn babies at 41 weeks and nine beyond 42 weeks. By comparison, 156,316 women delivered at 40 weeks, their due date, which included 128 stillbirths.
‘about a third of stillbirths occur at term, after 37 weeks of pregnancy,’ confirms Professor Khalil. a further third of stillbirths are of extremely premature babies (born before 28 weeks).
a key piece of evidence that NICE used to make its new recommendation was a Swedish study from 2019 which compared women who were induced at 41 weeks with those induced at 42 weeks. It was halted early on ethical grounds, as there were five stillbirths (and one death shortly after birth) in the group induced at 42 weeks, but none in the 41-week group.
That same year, an analysis of data from 15 million pregnancies published in the journal PLoS Medicine, showed that the risk of stillbirth increases slightly but steadily for every week a pregnancy goes on after 37 weeks. By 42 weeks, the rate of stillbirths rose to more than three per 1,000, compared with 0.11 per 1,000 at 37 weeks. ‘The risk increases as the pregnancy advances,’ says Professor Khalil, one of the authors of the PLoS Medicine study. ‘The most popular theory is that the placenta ages and becomes less efficient at delivering oxygen and nutrition to the baby.’ However, while the increased risk is significant, especially beyond 41 weeks, the overall risk remains small. Maria Booker, of the maternity care charity Birthrights, says that while they do hear from women who requested an induction and were denied it, they are contacted by many more ‘who feel coerced into having an induction’.
ANd induction is not always straightforward — typically it involves the use of hormone-like substances to soften the cervix, followed by the woman’s waters being broken manually, and a hormone drip to stimulate contractions.
Induction can lead to more internal examinations and can be associated with an increased risk of instrumental delivery, which can add to the risk of complications, such as vaginal tearing and post-natal incontinence.
Induced labour is also thought to be more painful (possibly because the artificial hormones don’t offer the degree of natural pain relief that a woman’s own hormones do); and there’s a small risk of the womb becoming over-stimulated, with contractions coming at very short intervals.
as well as being very painful, it can cause distress for the baby, and the induction has to be stopped.
However, ‘the quality of information that women receive on induction is particularly bad,’ says Maria Booker.
‘Many are just told [if you don’t have an induction]: “your baby might die” or “We need to induce you on Friday.” There’s not enough discussion of the alternatives, the risks or what the process involves.’
according to a 2018 review by the respected Cochrane group, 426 women have to be induced to prevent one additional perinatal death (which includes stillbirth, and babies who die shortly after birth). ‘But I don’t think women
have any idea that that’s the level of risk we’re talking about,’ says Maria Booker. ‘All women should be given a figure to put the risk in context.’
She argues that ‘we also need to think more holistically about how we tackle stillbirth, such as reducing levels of smoking and obesity in society as a whole’ — both are known risk factors.
Professor Khalil agrees there are other important measures, such as ‘improving the detection of small babies who suffer from growth restriction, improving awareness among pregnant women of reduced foetal movements, and improving training for healthcare professionals in foetal heart monitoring during labour’.
Already one in three births in the UK is the result of an induced labour. Dr Christine Ekechi, a consultant obstetrician and gynaecologist at Queen Charlotte’s & Chelsea Hospital, London, says that if more women are induced earlier than the current guidance recommends, then the additional strain on maternity care needs to be considered.
‘Wherever we bring in a new intervention, we have to increase the capacity throughout the whole process — if we don’t have the doctors and midwives to look after women, or the capacity to perform the induction of labour, then we’ll run into the same problems,’ she says.
There are already concerns about staff shortages: in a recent survey by the Royal College of Midwives eight out of ten midwives reported that there were not enough staff on their shift to provide a safe service.
Unfortunately, there are few alternatives when it comes to identifying which pregnancies are at risk of stillbirth.
CURRENTLY, women should be monitored for signs their baby is small for its age or its growth is slowing down. But size on its own is not enough, says Professor Khalil, especially later in pregnancy (‘only a third of stillbirths after 34 weeks are small’).
‘Currently, induction is the only intervention that we have evidence reduces the risk of stillbirth — if you induce everyone at 41 weeks, you eliminate stillbirth beyond 41 weeks,’ she says.
‘Stillbirth is a tragedy, and I do think it would justify inducing large numbers of women to prevent one case of stillbirth. But we need to be clear: it’s not for us to make this decision. It’s our job to give accurate information to pregnant women so they can make their own choices.
‘Unfortunately, this is an area where there’s still potential misinformation and confusion, both among the public and healthcare professionals.’
Despite being classed as having a higher-risk pregnancy because of her high BMI prepregnancy, Georgina Hardy, 28, wasn’t given the option of an early induction — a decision she now questions, after her daughter, Rosie, was stillborn in February 2019, a week past her due date. There was never any discussion about the rate of stillbirth going up after a certain point,’ says Georgina, a sales co-ordinator who lives in Clacton-on-Sea with her partner Dave, 29, a lecturer.
Despite being warned repeatedly about the danger posed by her weight and going into hospital three times with reduced foetal movements, Georgina was simply booked in for an induction at the standard 42 weeks.
Before it could take place, Rosie stopped moving for a fourth and final time. At the maternity unit, a midwife tried and failed to find a heartbeat.
GEORGINA recalls: ‘When the consultant came with a portable scanner, I couldn’t look at the screen.’ She believes the guidance on inductions should change. ‘If I’d known what the risks were, I would have jumped at the chance of an induction,’ she says. ‘After Rosie died, the more I read up on the subject, the angrier I got. I couldn’t understand why I didn’t know any of this.’
While nothing can replace the babies they lost, both Georgina and Alex have gone on to have another child.
Georgina gave birth to a girl last year, named Victoria-Rose, and in April Alex had a baby boy, Ellis.
Both say their experience was very different this time around; because of what happened before, they saw the same midwife and consultant at every appointment. Continuity of care has been shown in itself to reduce the risk of stillbirth, although this isn’t something all pregnant women experience.
‘It sometimes felt like my first baby had to die so that I could be treated properly with my second,’ says Georgina, who had a caesarean at 38 weeks with Victoria-Rose.
‘It shouldn’t take losing a baby to be listened to,’ echoes Alex, who has started an Instagram page to raise awareness around stillbirth (@marnie_in_the_ stars). She has since been told by a specialist that if she’d been induced earlier, Marnie would almost certainly be alive today.
Alex says it is indescribably painful to consider that, had the new recommendation been brought in sooner, Marnie might have lived.
‘But I have to feel like I’m doing something, by talking about this,’ she says. ‘A lot of people think there must have been a reason she died, or that it “wasn’t meant to be”. But there was nothing wrong with her. She was so beautiful and we miss her so much.’ new hope: Georgina and David with their daughter Victoria-rose