Since 1999, there have been huge advancements in medicine and technology. We no longer rely on clunky digital watches. Neonatal screening has improved, and the impending threat of Y2K has passed.
Despite these huge improvements, one thing hasn’t changed in 20 years: Australia’s stillbirth rates. Approximately six babies are lost to stillbirth every day in Australia, at a national rate of around 6.8 deaths per 1000 births in 2015 and 2016 according to a report by The Australian Institute of Health and Welfare.
In December last year, The Senate released its report on Stillbirth Research and Education — the recommendations of which have only just been accepted by the Morrison government. In line with the recommendations, the government has pledged to reduce the rate of stillbirth by at least 20% across five years.
Why this rate hasn’t been reduced in two decades seems to come down to two factors: we don’t know, and quality of care.
What we just don’t know
Authorities have no idea what causes nearly one in five stillbirths. The second-highest cause of stillbirth is unexplained death. Yet autopsies are performed in less than half of cases.
Currently, any blood tests performed on stillborn babies do not qualify for Medicare rebates. Autopsies can cost anywhere between $600 to nearly $3000 depending on the complexity of the examination.
Given women living in disadvantaged areas in Australia are 25% more likely to have a perinatal death, autopsy costs are often too much for many parents to afford. Hospitals are also often reluctant to perform autopsies due to budget restrictions.
As Dr Diane Payton, chair of the Royal College of Pathologists of Australasia’s Paediatric Advisory Committee pointed out in the Senate inquiry:
When you add up the performance of the autopsy and the reporting, for which they could have been reporting 60 small biopsies, and they would have had money coming in, or medical benefits accrued — the sort of funding they count on their books — whereas for the autopsy there is nothing.
Australia also does not have a national perinatal mortality audit program, meaning there is no constantly updated, easy-to-access database to glean insights into stillbirths. In fact, in 2013-14, of the thousands of deaths that occurred in the weeks directly before and after birth, less than 4% were reviewed for contributing factors.
While Health Minister Greg Hunt has announced the government will invest $52.4 million in perinatal services and support and improve access to publicly-funded stillbirth autopsies, it comes eight months after the Inquiry’s recommendations were made.
Without knowing the specific circumstances of a baby’s death through autopsies and national audit programs, opportunities for prevention are often lost.
Quality of care
According to the Centre of Research Excellence in Stillbirth, quality of care provided is a contributing factor to death in 20-30% of stillbirths.
Of the dismal approximately 4% of stillbirth cases reviewed by a jurisdictional perinatal review committee in 2013-14, a whopping 58% were found to have contributing factors including professional care.
Public hospitals have been swamped as women with private healthcare turn away from private hospitals, opting to give birth in public facilities to avoid exorbitant fees. In one hospital, a midwife had 12 women and their babies to look after in a single shift. With 27,000 more births to cope with, public hospitals often discharge new mums within 24 hours of giving birth, even after a caesarean.
There’s not supposed to be any difference in the quality of care between public and private hospitals — but those who can afford the copayments wouldn’t expect to be kicked to the curb less than a day after bringing life into the world.
The inequality of care doesn’t just differ between public and private hospitals, but between regions. DIY birthing kits have been handed out to mums-to-be in rural Queensland, while maternity services in rural and remote areas are left unmaintained, with baby mortality rates in rural areas without birthing clinics four times higher than those with clinics.
It’s estimated less than 10% of Australian women receive continuity of midwifery care, according to the Senate Inquiry, which involves seeing the same midwife through pregnancy. Pregnant women will generally not see the same doctor for every appointment, with appointments lasting less than 15 minutes.
Without improvements to quality and quantity of data, to analyse trends and implement preventative measures, and without vast improvements to healthcare including access, increased hospital beds, and staff to patient ratios, the Morrison government’s aim to reduce stillbirths for the first time in 20 years seems unlikely.
Still a way to go to achieve the appalling maternal and neonatal morbidity rates happening in some states in the US. Here, many services like baby health clinics, pioneered by the CWA in rural areas have gone. Good discharge planning and follow up for at risk mums and bubs is the exception rather than the rule. There are great nursing clinicians but they are hampered by poor planning and adequate and consistent funding.
Whilst I agree with your first sentence, I would point out that ‘neonatal morbidity’ has nothing to do with stillbirth. In the first instance, a neonate is a living, breathing entity…if only for a very short period…but a stillbirth does not have that distinction under the law. In other words the ‘baby’ was born dead…never lived.
I was a midwife for the best part of 50 years and must say I am gob-smacked by these figures. Having worked in all types of hospitals, urban and rural, in two countries, stillbirth was a rare event during my career, especially in large city obstetric hospitals. The only possible exception to that observation, is the number of very premature…less than 25 weeks gestation births, where survival rates, while better today, have never been very good. Once upon a time, viability was 28 weeks, and IMHO is far more realistic.
The answer to some of these stillbirths, is first-class ANTE-natal care, preferably by a team of midwives assigned to the same pregnant woman throughout, with oversight by an obstetrician. But as with most other types of healthcare today, this is a very expensive system, and the money to run such schemes just isn’t there.
Governments are far too busy propping up the private sector to fund this type of care for all!
Thanks for correcting my bad CML. I totally agree with every point you make. Another example of the unravelling of our great public health system which included early intervention and education.
Thank you. My first child (born at 30 weeks) died after an incompetent and racist doctor killed him. This remote Australian hospital in 1987 still had segregated wards- for Aboriginal and non Aboriginal patients. It was hopelessly under funded and under resourced.
One of the obstitricians was known in the community for her racist attitudes towards Aboriginal people.
There are many other deaths, other horror stories about this hospital. White people used to say “if in pain catch a plane’ and thats what they did. For Aboriginal people there wasnt this choice.
This needs to be investigated. I believe that racism and racist attitudes held by hospital staff will be found to be a contributing factor to the higher rate of deaths of Aboriginal babies.
Their seems to be a cloak of secrecy around the cause of stillbirths. Especially given the seeming lack of will by authorities to get to the bottom of it all. According to some sources there is even evidence that obesity plays a role, although this is vigorously disputed by other sources.
I don’t think you can even pin it on public verses private or rural verses city due to the equivalence of prenatal care. It’s a mystery.
It would be interesting to know if women who have suffered stillbirths had been exposed to mercury during the pregnancy. Mercury does accumulate in the fetus. There is the obvious suspects, but even Dental amalgams could do it. There is some interesting data out there if you “dig deep.”
”the Morrison government’s aim to reduce stillbirths for the first time in 20 years seems unlikely.”
I gather women voted for the Coalition in the last 20 years and rural and regional women in National Party safe seats in particular.
A glance at how many women are on Liberal and National party benches should tell you girls what the conservatives think of women.