Oghome Emembo is the National Lead, Stillbirth Prevention and Care (SPEED) Initiative. In this interview with NKECHI ONYEDIKA-UGOEZE, she explains how the absence of self-prenatal care, congenital syphilis, constant exposure to carbon monoxide and gaps in emergency obstetric care worsen stillbirth cases in the country.

There are nearly 1.9 million stillbirths annually, with more than 40 per cent occurring during labour.

Most stillbirths could be prevented with quality healthcare. What is stillbirth, what signs may indicate it, and what are the major risk factors?
According to the World Health Organisation (WHO), stillbirth is the loss of a baby at or after 28 weeks of gestation, either before or during labour. Several factors can contribute to stillbirth, including inadequate self-care during pregnancy. While clinical management is essential, pregnant women should register for antenatal care as early as possible and complement it with appropriate self-care practices.

Self-care during pregnancy involves the knowledge and adoption of practices within a woman’s control that can help protect her health and reduce the risk of complications, including stillbirth. Attending antenatal appointments alone may not be enough if a woman’s lifestyle or environment undermines the benefits of clinical care.

For instance, exposure to carbon monoxide from cooking with firewood or other polluting fuels, as well as second-hand smoke, can pose risks during pregnancy. A woman may attend antenatal appointments, take folic acid, and receive medical examinations but still inhale harmful pollutants at home or at work.

Research has linked carbon monoxide exposure to foetal hypoxia, a condition in which an unborn baby receives insufficient oxygen, potentially leading to serious complications.

Another consideration is sleeping position in late pregnancy. Pregnant women are advised to sleep on their side, left or right, rather than on their backs. If a woman wakes up lying on her back, she should turn onto her side. Sleeping on the back in later pregnancy can compress major blood vessels, reducing blood flow to the baby.

Syphilis during pregnancy is another important risk factor. The infection can pass from mother to child and cause serious complications, including stillbirth.

Although the WHO promotes dual HIV and syphilis testing and the triple elimination initiative, some pregnant women remain unscreened. Others do not attend antenatal care and may consequently miss essential screening, treatment and preventive interventions. Women who attend antenatal care should ensure that they are screened for syphilis. Integrating syphilis testing with HIV screening has made the process easier in many settings.

Awareness of foetal movements is also important. Pregnant women need to understand their baby’s usual movement patterns and seek prompt medical attention if they notice a significant reduction or change in movement.

Complications can develop between antenatal appointments, making it important for women to remain attentive to their health throughout pregnancy. They spend much more time outside healthcare facilities than within them, so they need the knowledge and support to recognise potential warning signs and seek care promptly.

Antenatal care should also include appropriate counselling and psychological support for women experiencing intimate partner violence. Healthcare providers must create a safe and supportive environment in which women feel comfortable discussing their concerns and circumstances. This can help providers identify risks early, determine appropriate interventions, protect maternal and foetal health, and improve pregnancy outcomes.

How can pregnant women become more involved in and aware of their pregnancy?
People living with hypertension are encouraged to monitor their blood pressure at home, while those with diabetes monitor their blood sugar levels.

Why, then, is there still a gap in the level of awareness and personal responsibility needed to help prevent stillbirths?
We sometimes hear of women attending weddings or social gatherings, unaware that their babies have died in the womb, perhaps eight or even 12 hours earlier. This raises serious questions about how women are involved in monitoring their pregnancies and recognising potential complications.

When people suspect they have a health condition, they often take steps to check their status. A woman who suspects she is pregnant may use a pregnancy test kit, while someone with diabetes may carry a glucometer to monitor blood sugar levels. However, a pregnant woman may be carrying a baby whose heartbeat has stopped without realising it. This highlights a gap in women’s involvement in prenatal care that must be addressed if we are to make meaningful progress in preventing stillbirths.

Another important issue is the absence of adequate perinatal bereavement care in Nigeria.

Perinatal bereavement care refers to the compassionate and respectful support provided to a woman after the loss of a baby during pregnancy or around childbirth. How she is treated by healthcare workers, her community and policymakers can significantly influence her psychological and emotional recovery, as well as her readiness for a subsequent pregnancy.

Unfortunately, such care remains largely absent in Nigeria. We are strongly advocating for change and hope to initiate and pilot a perinatal bereavement care protocol in the country.

The way women are spoken to and treated after stillbirth matters. So do the stigma, harassment, sociocultural practices and beliefs they may encounter. In our society, a woman’s womanhood is often judged by her ability to become a mother. You can imagine the emotional burden this places on a woman who has experienced stillbirth.

Such painful and stigmatising experiences can undermine her psychological and emotional recovery, complicate the grieving process and affect her confidence about conceiving again and carrying a subsequent pregnancy to term.

What warning signs should women look out for to help prevent stillbirth?
There are general warning signs during pregnancy that should prompt a woman to seek immediate medical attention, although these signs do not occur in every case. One woman may experience certain symptoms while another may not, which is why personal awareness and involvement in pregnancy care are essential.

One warning sign is vaginal bleeding during pregnancy. Another is a change in the baby’s movements.

Research shows that it is not only reduced foetal movement that matters; changes in the usual pattern of movement are also important. If a woman notices a significant change in her baby’s movements, she should seek urgent medical assessment.

Women with a history of recurrent stillbirths or previous pregnancy complications, including pre-eclampsia, also require close clinical monitoring.

Gestational diabetes is another condition that needs appropriate management throughout pregnancy to reduce the risk of complications.

These conditions require careful monitoring and timely intervention to help improve pregnancy outcomes and reduce the risk of stillbirth.

Every woman’s experience is different, and symptoms may vary from one pregnancy to another. While general warning signs are important, a person-centred approach to antenatal care remains essential. Healthcare providers must recognise each woman’s individual circumstances and risks, while ensuring that she understands when and how to seek medical help.

Nigeria has one of the highest stillbirth rates in the world, estimated at 46.2 per 1,000 births. Why is the rate so high, and which women are most at risk?
I would not categorically say that any particular group of women is inherently more prone to stillbirth without evidence to support that claim. Stillbirth can occur in any pregnancy, particularly when adequate clinical care and appropriate self-care practices are lacking.

The burden in Nigeria is substantial, with more than 400,000 stillbirths reportedly recorded annually. However, more recent data from the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) puts Nigeria’s stillbirth rate at 23.8 per 1,000 births.

This is almost twice the global target of 12 stillbirths per 1,000 births. Nigeria’s rate of 23.8 compared with the target of 12 shows the scale of the challenge.

To make matters worse, United Nations estimates suggest that Nigeria may not achieve the target until 2087. Nigeria’s Every Newborn Action Plan (ENAP) also uses the UN estimates because of significant gaps in the quality of national data, which can affect the reliability of local analyses.

However, Nigeria’s national Every Newborn Action Plan sets a target of reducing stillbirths to 19 per 1,000 births by 2028.

Nigeria has an Every Newborn Action Plan, which shows that the Federal Government, is making efforts to reduce the country’s contribution to the global stillbirth burden. Why has the rate of reduction remained so low over the decades?
The major reason for Nigeria’s slow progress is poor data governance. If you do not count a problem, you cannot measure it accurately, and if you cannot measure it, you cannot effectively address it. Reliable figures are essential for understanding the scale of the problem and developing appropriate interventions.

Many stillbirths are not captured by the data reporting systems used by the Ministry of Health. The systems are not robust enough, and even the data collected are not adequately analysed or used. Data quality assurance is also weak.

Until we establish an accurate picture of what is happening at different levels of government, we will continue to struggle. We need reliable data from community-level surveillance and wards through local government areas and states to the Federal Government. This would give policymakers a clearer understanding of the actual burden of stillbirths across the country.

The District Health Information Software 2 (DHIS2), which is used for health data reporting, captures more data from primary healthcare (PHC) facilities than from secondary facilities, where many complicated pregnancies are referred for care.

Primary healthcare facilities, however, are closer to communities, including underserved populations where the burden of stillbirths and health inequities may be high. We therefore need to strengthen data collection and reporting across all levels of the health system.

Poor data governance remains a major challenge. Strengthening stillbirth surveillance and reporting systems is fundamental to understanding the problem, tracking progress and preventing avoidable deaths in Nigeria.

Studies show that more than 50 per cent of stillbirths in Nigeria occur during labour. What critical gaps exist in emergency obstetric care at primary and secondary healthcare facilities?
These are intrapartum stillbirths, which occur during labour. One critical gap is the need to upgrade the skills of nurses and midwives who manage obstetric emergencies.

Regular refresher training is essential to ensure that midwives remain up to date with best practices, new technologies and research. I would recommend annual training or, where possible, twice a year. We need to learn from countries that have made progress towards the global stillbirth reduction target by examining their data and how they manage obstetric emergencies.

We cannot have a situation in which a midwife says their last refresher training was three years ago. Healthcare needs are constantly changing, as are environmental conditions and women’s experiences. Midwives and obstetricians therefore require regular training and professional development to provide safe, effective care.

Another critical challenge is inadequate infrastructure in healthcare facilities. Emergency obstetric care in Nigeria is constrained by shortages of beds, insufficient staffing and limited capacity to manage complications.

A woman in labour may be experiencing pain and progressing through cervical dilation, only to be told to go home because there is no available bed. Even when a bed is available, there may be too few healthcare workers to monitor her adequately, as staff on duty may already be attending to several other patients.

The situation has been compounded by the migration of skilled healthcare professionals to countries such as Canada, leaving many facilities struggling with staff shortages alongside existing infrastructure deficits.

Consider a woman living in Badagry who is turned away from a health facility and told to return home. The distance she must travel could make it more difficult to access urgent care if complications arise. Even where a facility is nearby, complications can develop quickly during labour, making close and continuous monitoring essential.

Women need to be cared for in facilities equipped to observe the progress of labour and respond promptly when it deviates from the expected course. Unfortunately, some women who are advised to return home choose to remain at the facility because they fear what might happen if complications develop.

Inadequate infrastructure and workforce shortages are therefore major obstacles to preventing intrapartum stillbirths, alongside poor data governance. Addressing these gaps requires investment in facilities, adequate staffing, regular clinical training and effective monitoring of maternal and foetal health during labour.

There are wide disparities in stillbirth rates between northern states, such as Zamfara and Katsina, and their southern counterparts. What factors drive these differences?
Northern Nigeria has experienced, and continues to face, significant insecurity and political unrest. These conditions can limit women’s access to healthcare facilities. When women feel unsafe travelling to hospitals or clinics, some may turn to harmful sociocultural practices instead of seeking appropriate medical care.

For instance, some women may rely on traditional concoctions or mixtures, drinking them or applying substances to their bodies rather than attending antenatal care. In some communities, women face a difficult choice between risking their safety by travelling to a healthcare facility and relying on potentially harmful practices at home. Insecurity is therefore an important factor.

Another challenge is inadequate access to healthcare facilities and the long distances women must travel to reach them. These barriers are often compounded by insecurity and unrest, contributing to regional disparities in stillbirth rates. Our research also found particularly high risks in states such as Zamfara and some other parts of the country.

Education and awareness among women are also important factors. People can only act on information they have, which underscores the need for effective, culturally appropriate health communication. We cannot rely solely on English-language messages. Information must be communicated in the local languages and dialects women understand, with clear explanations of the dangers of myths, misconceptions and harmful cultural practices during pregnancy.

There are several sociocultural factors to address through targeted risk communication, alongside improvements in security, access to healthcare and maternal health services.

Read the remaining part of this interview on www.guardian.ng