When we think about stillbirth—or the death of a fetus during delivery or in the womb after at least 28 weeks of pregnancy—we often focus on the emotional trauma it can cause for entire families. But a study published last month revealed we had no idea how physically dangerous stillbirth can be for pregnant people.

Patients who deliver stillborn babies are nearly five times more likely to experience life-threatening complications than those who have live births, according to a study published last month in the journal Obstetrics and Gynecology. The study, which used data from nearly 6.5 million deliveries in California between 1999 and 2011, found that women who had stillborn babies were nearly five times as likely to experience “severe maternal morbidity”—defined as at least one of 18 possible complications including blood transfusion, acute renal failure, and respiratory failure requiring intubation. Severe maternal morbidity indicators can be life threatening and are strongly linked to maternal deaths, according to a 2018 study. 

“I mean, it’s appalling,” said Alex Butwick, one of the study’s authors. Butwick works as an anesthesiologist and professor at Stanford University Medical Center. He said that he expected to find a higher rate of complications for stillbirths than live births, but nothing of this magnitude, “Nearly one in 17 women that have a stillbirth … experience at least one maternal morbidity,” he said.

Childbirth-related illnesses and deaths have climbed in the United States in recent decades, even as they’ve declined elsewhere. The rates are especially high among women of color, particularly Black women. As the study’s authors note, however, these numbers often don’t include people who have had stillbirths. “Prior population-wide studies of severe maternal morbidity have either excluded stillbirth deliveries, combined stillbirths and live births, or adjusted for stillbirths as a fetal outcome,” they write. In other words, past research never considered people who deliver stillborn fetuses as a unique population—and in some cases, they were left out of research altogether.

Black women and women without higher education degrees are more likely to deliver a stillborn fetus, according to a 2009 study. Now that we know stillbirth is also significantly more dangerous than live birth, the fact that it’s more common among Black women adds to the mountain of evidence showing that pregnancy is especially dangerous for them.

The new Stanford research is the only large-scale study to investigate the relationship between stillbirth and maternal morbidity. Butwick says the dearth of previous research is part of the same trend that’s given the United States one of the highest maternal mortality rates in developed countries—that is, a trend of undervaluing pregnant people’s lives.

Maya Dusenbery, author of Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick, agrees. “The entire kind of system we have is very focused on ensuring a healthy baby,” said Dusenbery. “And the health of the pregnant person is a little bit secondary.”

Butwick says that while the study shows how wide the maternal morbidity gap is for stillbirths versus live births, there’s still a lot of data missing that could help medical professionals understand why stillbirths can be so dangerous for the pregnant person. The study acknowledges that available data doesn’t always include the cause of fetal death, which makes it harder to draw correlations with maternal health complications. And, says Butwick, we don’t know if patients who come into the hospital to deliver a stillborn baby receive the same “overall package of care” as those who come in for live births—especially when they know in advance that the baby is going to be stillborn.

“Are the same surveillance systems for these morbidities in place?” he asked. Since we don’t know, it’s hard to determine if patients experience life-threatening complications during delivery happen because of the care (or lack thereof) they’re receiving, or for the same reasons that they had a stillbirth in the first place. The total, long-term mental and physical consequences stillbirth has on patients is even more of a mystery.

“I cannot imagine what the impact must be emotionally and psychologically of incurring a morbidity on top of a stillbirth delivery,” said Butwick. Once they’re discharged, he said, “we have no idea what sort of impact that double hit has on these poor women,” because of a lack of research and follow-up care.

Dusenbery said that when researching pregnancy and childbirth, she noticed a normalization of all sorts of associated traumas.

“There’s so much silence and misinformation about what really is normal when it comes to postpartum healing,” Dusenbery said, “and so much room for potentially life-threatening problems, to be dismissed as like, ‘Oh, what did you expect, like you just went through childbirth.’” She said she imagines that “with a stillbirth that there’s a similar dynamic, and also potentially even more of a tendency to just normalize any problems.”

“There’s obviously systems issues here,” Butwick said. The evidence that’s come to light about maternal mortality in the United States has shown that maternal care during pregnancy and childbirth is inadequate and, Butwick said, that might be even more true for pregnant people experiencing stillbirth. While we still need to better understand what’s causing these morbidities, he said, care should be improved now.

“My personal feeling is that if you’ve got 1 in 17 women who are delivering a stillbirth experiencing severe maternal morbidity, that frequency is high enough, where we should probably ensure that we’re improving care for every single woman that has a stillborn pregnancy,” he said.