When Christine Jonas-Simpson's son Ethan was born, there was an eerie quiet in the delivery room, and then a piercing wail.
"The only cry I heard was my own," she said sombrely.
Ethan was dead, "born still" in the language of grieving parents; "stillborn" in the medical vernacular. The umbilical cord was constricted, essentially suffocating the baby in the womb, a condition impossible to detect with an ultrasound.
Ms. Jonas-Simpson, who was almost 38 weeks pregnant, knew her son was dead before she went into labour. When he was born, she held Ethan in her arms, stroking his shock of curly red hair. So did her husband.
The nurses were wonderfully supportive, even explaining to Ethan's young siblings how his air tube was broken, something that could happen to an astronaut. The family was able to mourn on their terms.
(Ms. Jonas-Simpson, a professor of nursing at York University, published a children's book, Ethan's Butterflies, and produced a series of research papers and documentaries on stillbirth, the latest of which, Enduring Love: Transforming Loss , will premiere in Toronto on May 15.)
Unlike Ethan, most babies born still are quickly "disposed of" without being held, named or given a funeral. In much of the world, reproduction is central to a woman's purpose, so there is profound stigma, and no small measure of blame falls on the mother when childbirth fails to produce a living child.
Newly published data show there are more than 2.6 million stillbirths worldwide each year. The deaths remain largely uncounted, the mothers unsupported and preventive measures understudied.
It is an epidemic – one that claims more lives each year than HIV-AIDS and malaria combined – that quietly unfolds far from the public eye.
The Lancet, in its Thursday edition, has published a series of articles that aim to shatter the silence by examining the staggering toll of stillbirth – emotional, physical and economic – and proposing practical solutions.
A stillbirth, as defined by the World Health Organization, is one in which a baby dies after reaching at least 28 weeks gestation and weighing at least 1,000 grams. In a country like Canada with advanced medical care, it is 22 weeks at 500 grams. (Loss of a fetus before that time is considered a miscarriage or, if the pregnancy is terminated, an abortion.)
There is a common belief that babies who die in utero were never meant to live. Stillbirths have been seen as a form of natural selection, bad luck, the result of witchcraft – lame 17th-century explanations for a lingering 21st-century scourge.
The other myth is that most stillbirths occur early in the pregnancy. In fact, the opposite is true: The longer the gestation, the higher the risk.
The vast majority of stillbirths are preventable.
In wealthy countries like Canada, where high-tech obstetrics are the norm, stillbirths are linked to smoking, obesity, advanced maternal age, and abnormalities in the placenta and umbilical cord.
Worldwide, fewer than 5 per cent are due to congenital abnormalities like anencephaly (lack of a brain stem), and many of those conditions are caused by lack of essential nutrients like folic acid.
The 1.4 million babies who die antepartum (before delivery) each year tend to succumb because their mothers have preventable or treatable conditions like syphilis, malaria, diabetes or hypertension.
The 1.2 million babies annually who die intrapartum (during delivery) do so because they lack access to even the most basic obstetrical care, such as a midwife who can assist with a breech birth, let alone access to emergency cesarean sections. These deaths are dismissively listed as resulting from "complications."
The real complications are poverty and lack of access to basic healthcare services for women.
Bear in mind that of the 130 million births worldwide annually, at least 60 million women deliver alone, invariably those who live in the most squalid conditions.
Needless to say, the vast majority of stillbirths occur in the developing world. Five countries – India, Pakistan, Nigeria, China and Bangladesh – account for more than half. China, it should be noted, has dramatically reduced its rate of stillbirths in recent years.
Worldwide, rates range from two per 1,000 births in Finland to 40 per 1,000 in Nigeria. Canada's rate is 3.3 per 1,000 births, but the rate of stillbirths is three times higher in Inuit and first nations communities than in the general population.
Stated bluntly, stillbirth is inversely correlated with wealth; the problem exists largely where there is rampant poverty, no education and poor housing, like all conditions that stalk mothers and children.
Each year, more than 400,000 women die in childbirth and about three million babies die. Stillbirth is the unspoken part of the puzzle.
In recent years, there have been determined – and fairly successful – efforts to keep mothers from dying while birthing and to protect babies from the infectious diseases, malnutrition and traumatic injuries that kill, thanks largely to investment in the Millennium Development Goals.
But reducing stillbirths is, inexplicably, not one of the millennium goals. The problem has largely been ignored by the global public-health community. Instead of a plan, there is fatalism.
In its articles, The Lancet not only exposes the problem but proposes solutions that include investment in family planning, obstetric care, bed nets to protect against malaria, and screening for syphilis.
These measures would, according to the published calculations, reduce stillbirths by 45 per cent, meaning 1.1 million fewer deaths a year. They would have the added spinoff effect of reducing maternal deaths by 54 per cent (201,000 fewer) and neonatal deaths by 43 per cent (1.4 million fewer).
In recent years, the focus has been on safe motherhood and on improved child survival after live birth. It is now time to put some effort into ensuring that fewer women have to endure high-risk pregnancies and that more children are born alive.
These lives that will never be lived, this source of incalculable heartbreak, cries out for attention.