Stillbirth prevention 1921 and 2016: the call for 'adequate antenatal supervision'.

Abstract

Prevention of stillbirth has been a goal of obstetrics for over a century. As Goldenberg et al. demonstrate in their model for prevention of stillbirths in sub-Saharan Africa, increased hospital care with fetal monitoring and access to caesarean section result in the greatest reduction in stillbirths (Goldenberg et al. BJOG 2018;125:119–129). Similarly, practitioners in the early twentieth century also sought to prevent stillbirth through increased use of hospitals, improved fetal monitoring and antenatal care. A 1921 case series of stillbirths by Francis J. Browne, a research pathologist at the Royal Maternity Hospital in Edinburgh, included causes such as craniotomy (delivery of obstructed labour by decompression of the fetal cranium), asphyxia neonatorum (antepartum or intrapartum), cerebral haemorrhage, syphilis and scopolamine–morphine narcosis (from the infamous ‘twilight sleep’; Browne. Br Med J 1921;2;140–5). Twenty-five years later, Evans et al. recorded causes of stillbirth after completion of autopsy at two hospitals in England. Asphyxia remained the leading cause of stillbirth, followed by infections and intracranial haemorrhage (Figure 1; Evans et al. J Obstet Gynaecol Br Emp 1946;53;440–52). Strategies for stillbirth prevention between 1921 and 1946 are strikingly similar to those used today. Evans called for ‘careful auscultation of the foetal heart in the second stage,’ just as Browne advised ‘keeping a careful watch’ on the fetal heart. Practitioners performed intermittent auscultation with a fetoscope, which, as Browne stated, could be very difficult with the ‘pains coming frequently, and the mother crying loudly’. Second, both argued for ‘adequate antenatal supervision’—something that was not performed, either routinely or as standard, until the second half of the century. Lastly, obstetricians argued for increased use and provision of maternity hospitals to achieve lower stillbirth and infant mortality rates (The Health Committee of the League of Nations. Br Med J 1930;13;441–2). Regular use of hospitals by labouring women was not commonplace until the mid-century. It is tempting to compare stillbirth in England a century ago to sub-Saharan Africa today. Of course, this is a gross simplification and an unfair representation of modern low-income countries. Granted, there are similarities regarding lack of access to prenatal care, fetal monitoring, hospitals and safe and timely operative delivery. However, the circumstances under which stillbirth prevention was attempted a century ago and that attempted in sub-Saharan Africa today are radically different. History teaches us that improving stillbirth rates is a long process that requires widespread change in medical practice, improvement in infrastructure, and close attention to cultural meanings and understandings of stillbirth. Even in high-income countries there is considerable room to further reduce stillbirth while decreasing the morbidity of interventions. Little did early twentieth century clinicians know that improved obstetric care would lead to its own set of difficulties (e.g. increased rates of caesarean delivery, placenta accreta and preterm birth). Just as in the early 1900s, identification of the causes of many stillbirths and the best methods of prevention remain elusive today. The author is grateful to Robert Silver, MD for editorial support. None declared. Completed disclosure of interests form available to view online as supporting information. ■ Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.