Giving birth to a stillborn child is a harrowing experience for parents and many eventually want to know what went wrong, in part to avoid going through a similar experience in the future.
But in the days after delivery, when tests to search for a cause must be conducted, doctors are often hesitant to suggest them and grief-stricken parents are often reluctant to permit them.
A recent study found that two tests are particularly effective in determining the cause of a stillbirth - death of a foetus at or after 20 weeks of gestation.
An examination of the placenta helped find a cause in about two-thirds of stillbirths and a foetal autopsy helped in about 40 per cent of the cases, researchers reported. And genetic testing helped to pinpoint a cause 12 per cent of the time.
About 26,000 women in the United States give birth to a stillborn child each year.
Stillbirths due to complications during the birth process.
Stillbirths due to genetic conditions or birth defects.
Stillbirths due to infection.
Stillbirths due to umbilical cord issues.
Dr Emily S. Miller, an assistant professor of obstetrics and gynaecology at Northwestern University, who was not involved with the study, said this new data would not only persuade more obstetricians and gynaecologists that placental testing "is something that we really need to recommend" but also help convince bereaved parents that follow-up testing is worthwhile.
The American College of Obstetricians and Gynaecologists has long recommended a slew of possible tests after stillbirths.
But this study, published in the journal Obstetrics And Gynaecology, is the first nationwide attempt to calculate the utility of the tests.
Researchers analysed 512 stillbirths from 2006 to 2008 from 59 hospitals in five states: Utah, Rhode Island, Massachusetts, Georgia and Texas.
Complications during the birth process, including premature rupture of the amniotic sac, accounted for 30 per cent of stillbirths, previous research showed.
Before labour, placental problems were the most common cause of stillbirth, accounting for roughly one-quarter of the cases.
Genetic conditions or birth defects accounted for about 14 per cent of stillbirths, infection for 13 per cent and umbilical cord issues another 10 per cent.
A detailed evaluation of the pla- centa is not always done after stillbirth because a perinatal patho- logist was not available or a doctor may not send it for analysis.
Some of that reflects the reluctance of parents.
"People are angry and upset. And they feel that it won't make a difference," said Dr Robert Silver, interim chairman of obstetrics and gynaecology at the University of Utah Health Sciences Centre and the study's senior author.
Some parents also have cultural objections to an autopsy or think it is God's will that they have suffered a loss, he said.
Physicians often struggle to have that difficult conversation with grieving parents.
Dr Silver said: "It's uncomfortable, but it's worth working through any reservation they may have."
Several experts said the very act of trying to find a cause can bring emotional healing to some parents, even if no cause is ultimately determined.
"Patients often come back after a loss wanting to know what their recurrence risk is," said Dr Kathryn Gray, a high-risk obstetrician at Brigham and Women's Hospital in Boston. "There's a lot of anxiety."
Despite the tests, some stillbirths remain unexplained. But Dr Miller said: "Feeling like we are doing everything we can to understand why can bring emotional closure."
NEW YORK TIMES