Explainer: The difference between miscarriage and stillbirth
In the Kenyan healthcare system, the threshold is set at 28 weeks. Losses occurring before this point are classified as miscarriages, while those occurring at or after are classified as stillbirths.
What you need to know:
- The boundary between a miscarriage and a stillbirth is one of the most misunderstood and painful divides in reproductive health.
- The distinction is primarily a matter of viability, the developmental milestone where a baby is thought to have a chance of survival outside the uterus.
Across Africa, pregnancy begins with anticipation, preparation, and the hope of welcoming a healthy baby. Yet, nearly one million families on the continent experience a stillbirth each year, a loss that is often hidden, uncounted, and unsupported.
Behind every stillbirth is a mother who carried her pregnancy expecting life, a family left without answers, a community carrying grief that rarely finds space in public discourse, and health workers forever impacted by the loss. These tragedies are not inevitable. Instead, they serve as urgent warnings, signals of where health systems are struggling and where women and newborns are not receiving the care they need and deserve.
Nation spoke to Dr Richard Mogeni, an obstetrician-gynecologist at Moi Teaching and Referral Hospital and chairperson of the Kenya Obstetrical and Gynecological Society (North Rift), to better understand stillbirths and how they differ from miscarriages.
What is the difference between a stillbirth and a miscarriage?
The boundary between a miscarriage and a stillbirth is one of the most misunderstood and painful divides in reproductive health. The distinction is primarily a matter of viability, the developmental milestone where a baby is thought to have a chance of survival outside the uterus.
In the Kenyan healthcare system, that threshold is set at 28 weeks. Losses occurring before this point are classified as miscarriages, while those occurring at or after are classified as stillbirths.
Within the category of stillbirth, timing further refines the classification. A fresh stillbirth occurs during the stress of labour, while a macerated stillbirth indicates that the baby passed away sometime before labour began.
Causes and risks
The origins of these losses often point to different biological drivers. For miscarriages, particularly those in the first trimester (below 12 weeks), the cause is overwhelmingly genetic. Nearly 80 per cent are due to chromosomal abnormalities in which the complex joining of sperm and egg does not result in a viable genetic blueprint.
In some cases, pregnancy loss through miscarriage is induced by the patient; either through medically assisted termination or clandestine abortion. Other cases may involve an incompetent cervix, a condition where the cervix lacks the strength to hold the baby inside the uterus.
Infections can also cause miscarriages. Recurrent urinary tract infections as well as infections such as malaria and viral illnesses like influenza can affect a pregnancy; often through the triggering of high fevers.
Stillbirths, however, are more frequently tied to the mother’s health or the environment of the womb. They include:
Medical conditions: High blood pressure (hypertension), diabetes, thyroid issues (hypo/hyperthyroidism) and systemic lupus.
Infections: Tropical diseases like malaria and TB as well as viral infections like rubella, syphilis or HIV.
Severe congenital abnormalities like severe heart diseases within the baby or difficulties in brain development.
Placental issues: Premature separation of the placenta or blood-group incompatibilities like rhesus factor incompatibilities that cause the mother’s body to reject the baby or physical trauma, such as a mother being hit or kicked in the abdomen.
Mother’s low blood levels: Iron is essential for the production of haemoglobin. Inadequate iron intake or absorption can result in anaemia during pregnancy, which can lead to complications for the foetus such as low birth weight, preterm birth, developmental issues and stillbirth.
Lifestyle and environment: The use of over-the-counter drugs or exposure to some chemotherapy drugs or certain chemicals can inadvertently trigger a loss.
How common are stillbirths and miscarriages?
The Kenya Demographic and Health Survey 2022 report noted that the country records 15 stillbirths per 1,000 pregnancies of 28 or more weeks' duration. However, the stillbirth rate was the highest among pregnancies of women aged between 40 and 49, up to 55 deaths per 1,000 pregnancies, compared to 38 deaths or fewer per 1,000 pregnancies among other age groups.
The highest perinatal mortality rates were recorded in Wajir (76 deaths per 1,000 pregnancies), Mombasa (57 deaths per 1,000 pregnancies), Siaya (54 deaths per 1,000 pregnancies), Murang’a (51 deaths per 1,000 pregnancies), and Kisumu (47 deaths per 1,000 pregnancies) counties.
According to Dr Mogeni, Kenya lacks adequate data on stillbirths, and the data often shared points to institutionalised stillbirths, where a foetus died while the mother was admitted to a health facility for delivery. This means that data of stillbirths happening in rural or marginalised areas without medical involvements are not recorded.
The ‘systemic’ stillbirth: Gaps in Kenyan care
Perhaps the most haunting revelation from Dr Mogeni is that many stillbirths are "system issues" rather than biological ones. In Kenya, birth asphyxia, where a baby dies during labour due to poor management, is a leading cause of loss in rural areas. Some ccounties like Marsabit have struggled without a resident gynecologist or pediatrician. Without these specialists, there is no one to audit near-misses or improve labour ward protocols.
Around 30 per cent of stillbirths are linked to delays in seeking care, often in areas where the distance between the mother’s home and a functional hospital is vast. In other cases, failure by pregnant women to attend antenatal clinic may contribute to stillbirths as complications cannot be arrested on time. Without skilled care, mothers in such areas lack adequate information, especially on danger signs to look out for, and often receive the warning or medical interventions late.
Can stillbirths and miscarriages be prevented?
They are preventable in two ways.
The first is by attending an antenatal clinic. When a mother attends the clinic, they undergo screening for blood levels to rule out low blood levels that can cause stillbirths, a miscarriage or spontaneous abortions. They are then given iron supplements
The mother is also screened for high blood pressure; blood group tests to see whether she would need rhesus factor management; urine to rule out infections; random blood sugar to rule out diabetes; and general blood tests to check for infections like tuberculosis HIV syphilis hepatitis B. Mothers are also assessed for mental health challenges that might put them and the children at risk.
The second form of prevention is management of conditions diagnosed during antenatal clinics. The management, says Dr Mogeni, is geared towards preventing miscarriages and stillbirths.
"If you have high blood pressure, you will be followed closely. Sometimes it might require that you be evaluated every two weeks. If you had a previous history of high blood pressure, for example at around 12 weeks, medics should be able to put you on some tablets that will postpone the beginning of another episode of high blood pressure in the current pregnancy. It might postpone it all the way to 28 weeks when the baby is viable, that is, if a decision is
made to deliver,’ says Dr Mogeni.
"Any woman who is not followed up and has very high blood pressure, diabetes or any other underlying medical condition might easily end up with a stillbirth,” he adds.
Navigating the medical process
When a loss is confirmed, the medical approach shifts from preservation to protection. For a stillbirth, the clinical preference is actually vaginal delivery rather than a Caesarean section. This is done to protect the mother’s future reproductive health and avoid the risks of major surgery when the outcome is already a loss.
During this process, the standard rules of labour are often rewritten.
“This is the only time we freely use labour medication for pain. In a normal birth, some pain relief is limited to protect the baby’s breathing, but in a stillbirth, the priority is the mother’s physical and psychological comfort. The goal is to ensure she is supported by a partner and stabilised through psychosocial counselling to begin the long journey of grief,” Dr Mogeni explains.
The woman is then investigated to find out what caused the stillbirth, so management can be directed to the cause of the stillbirth.
Healing begins with what Dr Mogeni calls preconception care. For a mother who has experienced a loss, the next pregnancy shouldn't start at a positive test. It should start months prior in their doctor's office.
“When a woman is planning to get pregnant, ideally they should talk to their doctor for preconception care so that prior complications can be managed early,” says Dr Mogeni.
