Gestational, perinatal and neonatal deaths are public health problems that profoundly affect families and impact health systems. Preventing these deaths requires a combination of interventions, such as early and adequate prenatal care, timely detection of complications during pregnancy, and constant monitoring of fetal well-being and quality care during delivery.

It is important to have clear definitions of these three situations, which may occur, in order to take timely actions to prevent them. Gestational death, also known as intrauterine fetal death, refers to the loss of a baby in the mother’s uterus. This term is used when the loss has occurred after the 20th week of gestation.

According to the World Health Organization (WHO), fetal death is the death before birth of fetuses “that have a birth weight of at least 1000 g, and/or a gestational age of at least 28 weeks, and a length of at least 35 cm.”(Maternal and perinatal death surveillance and response: implementation support material, WHO, 2022).

Perinatal death refers to the death of the fetus or newborn, when it occurs from 28 weeks of pregnancy up to the first 7 days of life. And, neonatal death is that which occurs within the stage that spans from the birth of the baby until the first 28 days of life.

As we can see, there are different periods from gestation, labor, birth and the first weeks of life, in which complications can occur that could lead to the death of infants. Therefore, at the de Waal Foundation we promote the early detection and management of risk factors, together with a safe and adequate birthing environment, are fundamental pillars to reduce gestational and neonatal mortality.

What factors cause these deaths?

According to data issued jointly by WHO, UNICEF, the World Bank and the Population Division of the United Nations Department of Economic and Social Affairs, a baby dies in the womb or is stillborn every 16 seconds worldwide.

The report A Forgotten Tragedy: The Global Burden of Fetal Mortality (Unicef, 2020) shows that 84% of fetal deaths occur in low- and middle-income countries.

“Most fetal deaths are due to poor quality of care during pregnancy and childbirth. More than 40% of fetal deaths occur during delivery, a loss that could be prevented with the assistance of a skilled health professional during delivery and timely obstetric care in emergencies,” the study notes.

The main causes of these deaths are complications during pregnancy, placental problems, genetic disorders and emergencies during childbirth. Among these factors are: placental abruption, aging or insufficient blood flow in the placenta, as well as multiple pregnancies and deliveries. Premature or preterm deliveries also predispose to infant death before 24 weeks of gestation.

In the case of fetal genetic problems, there are congenital malformations such as neural tube defects or anencephaly, due to the lack of brain development of the fetus. Difficulties with the umbilical cord, such as knots or compressions that can cut off oxygen to the fetus and cause gestational and perinatal mortality.

Among the pathologies that can develop in pregnant women and cause the death of fetuses are high maternal blood pressure, which causes preeclampsia, gestational diabetes and infections, which can cause premature births or affect the growth and development of the baby in the womb.

How to prevent them?

One of the main tools to prevent gestational, perinatal and neonatal death is pregnancy planning. From the de Waal Foundation we promote a culture of prevention, so we believe that a 12-month pregnancy, which consists of a minimum of 3 months of preparation before pregnancy, added to the 9 months of a careful and conscious gestation, reduces the possible deficiencies and diseases, as well as the risks that can cause these deaths.

In the preconception consultation, it can be established whether the couple, especially the mother, has any of the risk factors we have pointed out, in order to address these health problems before pregnancy and reduce the risk of infant death.

Poor nutrition is dangerous for the mother and her unborn baby. Lack of good nutrition before and during pregnancy exposes the baby to poor development in the womb and underweight, which can be life-threatening. In this sense, to prevent neural tube defects, which as we have seen, can cause these deaths. Studies by the Centers for Disease Control and Prevention (CDC) estimate that if all women of childbearing age consumed 400 micrograms of folic acid daily, 50% to 70% of all cases of spina bifida and anencephaly could be prevented.

Gestational bereavement: How to face it?

The loss of a baby, whether in the womb, at the time of delivery or shortly after birth, takes a great emotional toll on parents and families.

Unfortunately these deaths occur frequently and despite this, they are issues that affected couples often do not talk about openly or rarely seek professional help to process such a sad and unexpected event.

It is essential to raise awareness, provide emotional support and create safe spaces in which to talk openly about these losses, to reduce social isolation and ensure adequate care, both emotionally and physically, since this experience is extremely exhausting and in the case of the mother, it is important to understand that she is not only facing the death of her baby, but that she is in the process of recovering from a medical intervention or childbirth.

We share a series of recommendations for dealing with gestational bereavement:

• Seek out professionals, support groups or spaces where you can talk openly about the loss you have suffered.
• Likewise, the company of empathetic family members or friends, with whom one can freely express emotions, expectations, and memories of the deceased baby is very important, in order to unburden oneself.
• Although it may seem obvious, it is necessary to accept the grieving process you are going through. As soon as possible, it is a big step to recognize the loss and face it, instead of refusing to see and live the reality.
• Go to all the check-ups recommended by the doctor or when emotional or physical discomfort appears, it is essential to go to the health services immediately.

SOURCES

• Maternal and perinatal death surveillance and response: implementation support material, WHO, 2022.
• A Forgotten Tragedy: The Global Burden of Fetal Mortality, Unicef, 2020.
• The true magnitude of stillbirths and maternal and neonatal death is underestimated, WHO, 2016.
• Prenatal death, WHO, 2020.
• A fetal death occurs every 16 seconds, according to the first joint estimates of the United Nations, WHO, 2020.
• What are the possible causes of stillbirths?NICHD, 2023.
• Periconceptional use of multivitamins and the occurrence of neural tube defects, Mulinare J, Cordero JF, Erickson JD, Berry RJ., 1988.
• Preventing neural tube defects with folic acid, Center for Disease Control and Prevention and PAHO, 2009.
• Preparing for pregnancy is taking care of your health, de Waal Foundation, 2019.
• Preconception and prenatal consultation prevents disabilities, de Waal Foundation, 2019.
• Good nutrition prevents disease at birth, de Waal Foundation, 2019.
• Folic acid, an ally in the prevention of disabilities, de Waal Foundation, 2023.
• Why it is essential to talk about the loss of a baby, WHO
• Guía de Atención al Duelo Gestacional y Perinatal, Dirección General de Cuidados, Humanización y Atención Sociosanitaria, Principado de Asturias, 2022.