Importance of prenatal care in reducing stillbirth

The concept of screening for complications prior to delivery originated more than 100 years ago. Initially, prenatal care focused on detecting pre-eclampsia to reduce maternal mortality, with visits weighted towards the third trimester. This, together with increasing hospitalisation and early delivery for women with pre-eclampsia, markedly reduced maternal mortality and reduced stillbirths as well. As maternal mortality declined, reducing preterm birth became a main objective of prenatal care, and prenatal care evolved to include maternal education and testing for other conditions. As prenatal care added in screening for fetal growth restriction, fetal heart rate abnormalities, and other diagnosable conditions that increase stillbirth risk, stillbirths decreased further. Nevertheless, although prenatal care can help reduce stillbirth, preventing stillbirth has rarely been one of its primary goals. As prenatal care continued to expand, based on the belief that doctors often recommended too many visits and investigations without benefit, studies evaluated the content, frequency, timing and costs of prenatal care. Perhaps the most influential study was the World Health Organization (WHO) Antenatal Care Trial (Villar et al. Lancet 2001;357:1551–64), which concluded that a schedule of four prenatal visits would lower costs without worsening outcomes; however, a reanalysis (Vogel et al. Reprod Health 2013;10:19) of the data and a recent meta-analysis (Dowswell et al. Cochrane 2015;7:CD00934) found increased stillbirths associated with fewer visits. Lavin and Pattinson evaluated this issue in three South African provinces, two with a reduced visit schedule, with a third retaining a higher number of visits (Lavin & Pattinson BJOG 2018;125:140–147). The biggest difference was a complete absence of visits between 32 and 38 weeks of gestation in the reduced visit provinces, as well as fewer visits overall. Although not a randomised trial, in the provinces with reduced visits the authors found increased rates of stillbirth at 38 weeks of gestation, coinciding with the gestational ages missing out on prenatal visits. These results were similar to the reanalysis of the WHO trial. Thus, the evidence that reducing third-trimester prenatal care visits is associated with an increased rate of stillbirth is mounting. Which conditions account for the rise in stillbirths is unclear, but the failure to diagnose pre-eclampsia and to deliver affected fetuses before they succumb is likely to play a role. Lavin and Pattinson found an association between hypertension and stillbirths in the provinces with reduced visits. This conclusion is plausible, as in low-income countries pre-eclampsia is a major killer of fetuses: whereas maternal mortality does not generally occur without an eclamptic seizure, most stillbirths are associated with pre-eclampsia (Goldenberg et al. Int J Gynaec Obstet 2011:113:91–5). Improved care for other conditions discoverable in the third trimester may also reduce the rate of stillbirths. In the reanalysis of the 2001 WHO trial, the authors suggest that in retrospect fetal mortality should have been given greater prominence in the original publication. As preventing stillbirths becomes a more visible goal of the maternal and child health agenda, attention to the important role of prenatal care in reducing stillbirths, especially in low- and middle-income countries, is warranted. Achieving small reductions in the cost of care, if they occur at all, at the expense of increasing stillbirths is not an acceptable choice. 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.