Unraveling the mystery of stillbirths one autopsy at a time

stillbirths, pregnancy

According to the WHO data, the stillbirth rate in Kenya is 19 per 1,000 total births as of 2019.  At least 53 per cent of stillbirths occurred during labour and birth while 47 per cent occurred during pregnancy.

Photo credit: SHUTTERSTOCK

What you need to know:

  • Every 16 seconds, an expectant mother gets a stillbirth, according to WHO. In a day, 5,400 stillbirths are recorded globally. This translates to over two million stillbirths every year.
  • According to the WHO data, the stillbirth rate in Kenya is 19 per 1,000 total births as of 2019.  At least 53 per cent of stillbirths occurred during labour and birth while 47 per cent occurred during pregnancy.
  • In sub-Saharan Africa, the stillbirth rate is 21 per 1,000 total births. This is seven times higher than the stillbirth rate in high-income countries in Europe, Northern America, Australia and New Zealand, where it is just 3 per 1,000 total births, according to a 2020 report of the UN Inter-agency Group for Child Mortality Estimation.

A vaginal delivery or caesarian section? This is the question Millicent Wanyoike was asked after doctors missed her son’s heartbeat. 

“The thought of being induced to push a dead baby overwhelmed me. Two hours in labour,” she tells Healthy Nation. “The scars are still fresh.”

For five years, between 2016 and 2021, Millicent lost three stillborn babies. She suspects that the first two losses were caused by entangled umbilical cords. However, she cannot explain the cause of the other death. 

During her first pregnancy, Millicent started running a fever and by the time she got to hospital, her baby was dead and had to be flushed out at 13 weeks.  Health workers at the facility did not give her a reason for the stillbirth.  All she was left to do was to find a way to cope with her loss. She informed her relatives and they buried her son. 

Millicent was determined to find out what had happened to her babies so she could prevent another tragedy. After the burial, she visited a gynaecologist, and several tests were done but all turned negative. 

She changed her doctor, who advised her to clean her womb – a procedure of getting rid of the lining of the womb and blood from where the placenta was attached. That was done. Another doctor advised her to undergo a cervical cerclage procedure (cervical stitching) suggesting that she had cervical incompetence.

With cervical incompetence, a pregnant woman’s cervix begins to dilate and efface (thin) before her pregnancy is full-term.

“This, I did. It did not help either,” she continues. She lost her second pregnancy at five months. 

With mounting pressure to have a baby, Millicent and her husband decided to use herbal concoctions to clean her womb. She was instructed to use the drugs for six months until her womb was prepared to hold another baby.

Immediately after the six months she conceived again but the cycle of bad luck continued, and she lost her third baby. Her dreams of motherhood vanished.

With the third pregnancy, she had started spotting at seven weeks She was placed on medication until the baby was 11 weeks. But two weeks later, she lost the baby, yet again.

Millicent notes that the loss of her stillborn babies saw her rejected by her in-laws, who even suggested that their son gets another wife who could sire children.

Losing a baby through miscarriage or stillbirth is still a difficult subject particularly in our African society.

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She is yet to go for tests to identify the cause of her babies’ deaths. She says she is not ready to try for another baby.  “Let me rest. If it is God’s plan that I will be a mother then I will just carry one to term but for now, I am not ready to go through another loss,”  says Millicent.

Stillbirth, according to the World Health Organization (WHO), is defined as the spontaneous death of a foetus at 20 or more weeks of pregnancy.  Few families are prepared when a baby dies prior to delivery. Many are left to navigate this difficult experience on their own.

Every 16 seconds, an expectant mother gets a stillbirth, according to WHO. In a day, 5,400 stillbirths are recorded globally. This translates to over two million stillbirths every year.

During labour

According to the WHO data, the stillbirth rate in Kenya is 19 per 1,000 total births as of 2019.  At least 53 per cent of stillbirths occurred during labour and birth while 47 per cent occurred during pregnancy.

In sub-Saharan Africa, the stillbirth rate is 21 per 1,000 total births. This is seven times higher than the stillbirth rate in high-income countries in Europe, Northern America, Australia and New Zealand, where it is just 3 per 1,000 total births, according to a 2020 report of the UN Inter-agency Group for Child Mortality Estimation.

According to the 2020 data by the United Nations Children’s Fund (Unicef), Kenya is ranked sixth in Sub-Saharan Africa with 31,300 stillbirths per year.  

Nigeria is leading with 177,000 stillbirths followed by the Democratic Republic of Congo 105, 300, Ethiopia, 77,700 and Tanzania 42,100 stillbirths. The data show that there has been an increase in the number of stillbirths in sub-Saharan Africa; with the burden in the region increasing from 26 per cent in 2000 to 45 per cent in 2021.

Stillbirth rates remain high in Kenya despite significant progress in reducing maternal, neonatal, infant and under-five deaths.

Dr Ahmed Kalebi, a consultant pathologist, tells Healthy Nation that stillbirths need to be investigated and an autopsy done to get to know the cause of the deaths. He adds that it’s difficult to reduce stillbirth rates if we don’t understand why they occur. “For the first loss, if the cause is evident such as an umbilical cord around the neck, then there is no reason for autopsy. A simple examination is enough,” he says. 

If a mother loses a second or third pregnancy, then there is a cause for alarm. An evaluation of the foetus, mother and the placenta needs to be done.  The placenta is where the baby’s lungs, kidneys, and other organs develop.

“What normally happens in Kenya, once a mother gives birth, a placenta is thrown away and the stillborn taken to the mortuary. Most of the causes of stillbirths are always missed because we throw away the placenta,” Dr Kalebi explains.  He continues: “All the tests done to the foetus may be negative but with a thorough investigation of the placenta, a problem with the mother can be identified early. The placenta must be kept aside for proper investigations.”

Another challenge in getting a placental examination is that it has to be suggested by a provider and the test has to be done by a specialised pathologist.  

“It has to be done by a perinatal pathologist, who specifically looks at early paediatric pathology as well as placental and foetal pathology.”

It is through the placenta examination that one is able to see how that placenta developed, damage that may have happened and infections in the placenta, which then gives clues as to why the stillbirth happened.

But in Kenya, the procedure is not often done because of a shortage of specialised pathologists in the sector and the cost of the test.

The country has less than five perinatal pathologists, with none in government hospitals. Although general pathologists can perform normal autopsies, perinatal pathologists undergo specialised training to help them know what to look for in cases of a stillbirth. 

It costs between Sh15,000 to Sh40,000 to perform the perinatal autopsy exclusive of other tests. The cost is neither covered by most private insurance covers in the country nor the National Health Insurance Fund. Families have to foot the bill.   “This is not an area that is heavily specialised on. We have less than five perinatal pathologists in the country, majority in private hospitals,” says a government official.

According to a report by the Centers for Disease Control and Prevention 2020, the cause of death in about one-third of stillbirths globally is never determined.

Another reason why most couples do not like requesting an autopsy is the trauma that comes with the procedure. “We need to find a way of speaking to a family and even performing a minimally invasive autopsy, only withdrawing samples without having to operate on the body,” Dr Kalebi says. 

Narrating a story on the number of investigation requests from doctors on mothers who lost their children while he was still practising, Dr Kalebi indicates that they were just few because in most cases the placenta would be thrown away and the baby’s body buried immediately. 

“It became difficult to investigate the cause of the deaths. In some cases, we would identify a problem in the mother but mostly the placenta needs thorough investigation,” he says. 

Dr Kalebi calls on hospitals to develop protocol requirements for an autopsy to be done after a stillbirth.  According to the WHO, prenatal autopsies can provide answers to many cases of stillbirths that countries are recording but are not often performed.  

“Foetal autopsy, placental examination and clinical information could reduce cases stillbirths that remain unexplained,” says the WHO. 

It is through the autopsy that Dr Karen Gibbins, who has published several researches on stillbirths, got to know the cause of her two stillbirths. Thereafter, the obstetrician-gynaecologist from the US received treatment and carried her subsequent pregnancies to term.

After losing her 27th-week pregnancy in 2018, she really wanted to know the cause of the death. She underwent several examinations including genetic testing and a placenta examination. Everything was okay. No infections, no abnormalities.  She requested for an autopsy. “If we had not done that autopsy, I would have lost my consecutive pregnancies,” says Dr Gibbins, who is also a maternal-foetal medicine specialist at Oregon Health and Science University.

From her results, she learned that she had a rare condition called gestational autoimmune liver disease — her body produced antibodies that attacked a growing baby’s liver. 

The condition gets worse and worse in each subsequent pregnancy and if not detected early, the possibility that future pregnancies would be affected is very high.

“Had it not been for the autopsy, I would be losing my pregnancies without knowing where the problem was. I underwent treatment and thanks to God, I was able to carry my frequent pregnancies to terms without any worry,” she said. 

Dr John Ong’ech, consultant obstetrician and gynaecologist, tells Healthy Nation that apart from just getting to know what killed the baby, mothers need to attend antenatal clinics religiously to avoid stillbirths. 

“When a mother visits antenatal clinics and it happens that she has a problem, it will be attended to early before anything serious happens. I attend to so many women when they are in their first trimester but in the subsequent trimester, the numbers go down. Women should visit antenatal clinics religiously when they are pregnant,” Dr Ong’ech says. 

During the more than three decades of his practice, Dr Ong’ech mentions that cord accidents and placenta complications are the most common causes of stillbirth in most women. 

“An entangled umbilical cord will automatically disrupt the flow of blood to the baby and the danger also comes when the placenta separates early from the inner wall of the uterus before birth. All these can be detected when a mother visits the clinic,” he says.

He notes that with a cardiotocography machine, which monitors a baby’s heart rate and a mother’s contractions during the third trimester, some stillbirths can be prevented. “With the machine, we are able to tell that the heartbeat stopped or it is still functioning. This can only happen when mothers come to the hospital. It becomes an emergency when the machine detects that the heartbeat is fading,” he says.

From WHO, childbirth complications, post-term pregnancy, maternal infections in pregnancy (malaria, syphilis and HIV), maternal disorders (especially hypertension, obesity and diabetes), foetal growth restriction and congenital abnormalities are some of the causes of stillbirth. 

Why is an autopsy important? 

According to Dr Kalebi, an autopsy is the careful examination of the stillborn’s body after death. It is performed by a perinatal pathologist. It is the best way possible to understand how and why the baby died.

It has to be performed with the consent of the parent. Although many tests are available to diagnose a disease, no test can give a diagnosis with the same degree of certainty as an autopsy.  

It discovers whether the medical problem has any genetic (hereditary) importance especially if you are planning to have more children.

The post-mortem test examines various body parts, tissues and organs. All body organs work together and when one organ is not functioning normally, it may cause problems in the others.

Before an autopsy is done, consent has to be signed by parents. Thereafter they sign forms giving the pathologist permission to perform the procedure.