Stillbirths: Where? When? Why? How to make the data count

Reproductive health, 2015

Stillbirth rates remain nearly ten times higher in low-middle income countries (LMIC) than high income countries. In LMIC, where nearly 98% of stillbirths worldwide occur, few population-based studies have documented characteristics or care for mothers with stillbirths. Non-macerated stillbirths, those occurring around delivery, are generally considered preventable with appropriate obstetric care. We undertook a prospective, population-based observational study of all pregnant women in defined geographic areas across 7 sites in low-resource settings (Kenya, Zambia, India, Pakistan, Guatemala and Argentina). Staff collected demographic and health care characteristics with outcomes obtained at delivery. From 2010 through 2013, 269,614 enrolled women had 272,089 births, including 7,865 stillbirths. The overall stillbirth rate was 28.9/1000 births, ranging from 13.6/1000 births in Argentina to 56.5/1000 births in Pakistan. Stillbirth rates were stable or declined in 6 of the 7 sites fro...

American Journal of Obstetrics and Gynecology, 2007

Objective-Our goal was to determine stillbirth rates in a multi-site population-based study in community settings in the developing world.

Reproductive Health, 2020

Background Stillbirth rates are high and represent a substantial proportion of the under-5 mortality in low and middle-income countries (LMIC). In LMIC, where nearly 98% of stillbirths worldwide occur, few population-based studies have documented cause of stillbirths or the trends in rate of stillbirth over time. Methods We undertook a prospective, population-based multi-country research study of all pregnant women in defined geographic areas across 7 sites in low-resource settings (Kenya, Zambia, Democratic Republic of Congo, India, Pakistan, and Guatemala). Staff collected demographic and health care characteristics with outcomes obtained at delivery. Cause of stillbirth was assigned by algorithm. Results From 2010 through 2018, 573,148 women were enrolled with delivery data obtained. Of the 552,547 births that reached 500 g or 20 weeks gestation, 15,604 were stillbirths; a rate of 28.2 stillbirths per 1000 births. The stillbirth rates were 19.3 in the Guatemala site, 23.8 in the ...

BJOG: An International Journal of Obstetrics & Gynaecology, 2014

Reproductive health, 2018

Stillbirth rates remain high, especially in low and middle-income countries, where rates are 25 per 1000, ten-fold higher than in high-income countries. The United Nations' Every Newborn Action Plan has set a goal of 12 stillbirths per 1000 births by 2030 for all countries. From a population-based pregnancy outcome registry, including data from 2010 to 2016 from two sites each in Africa (Zambia and Kenya) and India (Nagpur and Belagavi), as well as sites in Pakistan and Guatemala, we evaluated the stillbirth rates and rates of annual decline as well as risk factors for 427,111 births of which 12,181 were stillbirths. The mean stillbirth rates for the sites were 21.3 per 1000 births for Africa, 25.3 per 1000 births for India, 56.9 per 1000 births for Pakistan and 19.9 per 1000 births for Guatemala. From 2010 to 2016, across all sites, the mean stillbirth rate declined from 31.7 per 1000 births to 26.4 per 1000 births for an average annual decline of 3.0%. Risk factors for stillbi...

Gates open research, 2023

Stillbirth, one of the most common adverse pregnancy outcomes, is especially prevalent in low and middle-income countries (LMICs). Understanding the causes of stillbirth is crucial to developing effective interventions. In this commentary, investigators working across several LMICs discuss the most useful investigations to determine causes of stillbirths in LMICs. Useful data were defined as 1) feasible to obtain accurately and 2) informative to determine or help eliminate a cause of death. Recently, new tools for LMIC settings to determine cause of death in stillbirths, including minimally invasive tissue sampling (MITS)-a method using needle biopsies to obtain internal organ tissue from deceased fetuses for histology and pathogen identification in those tissues have become available. While placental histology has been available for some time, the development of the Amsterdam Criteria in 2016 has provided a useful framework to categorize placental lesions. The authors recommend focusing on the clinical history, the placental evaluation, the external examination of the fetus, and, when available, fetal tissue obtained by MITS, especially of the lung (focused on histology and microbiology) and brain/cerebral spinal fluid (CSF)

Int Health, 2019

Annually, an estimated 2.6 million stillbirths occur worldwide.1 With five deaths every single minute, stillbirth is the fifth leading global cause of death when compared with causes of death in all age categories—outranking diarrhoea, HIV/AIDS, TB, road traffic accidents and any form of cancer.2 The vast majority (98%) of stillbirths occur in low- and middle-income countries (LMICs). This has also been referred to as the ‘silent epidemic’. Sadly, there is an increased risk of experiencing another stillbirth in subsequent pregnancies for women who have given birth to a stillborn baby before compared with those who have not.3 Furthermore, in most LMIC settings, bereavement care for parents is either not available at all or substandard.4 There is also still a paucity of information from LMICs regarding what causes stillbirth. To achieve the global target of reducing the stillbirth rate to 12 per 1000 births in every country by the year 2035, as proposed by the World Health Assembly (2014), the current annual reduction rate of 2% will need to be more than doubled. Several factors impede progress in the efforts to reduce the burden of preventable stillbirths. We highlight where and how focused interventions and implementation research is needed and would be effective.

Lancet, 2011

for The Lancet's Stillbirths Series steering committee* Stillbirth rates in high-income countries declined dramatically from about 1940, but this decline has slowed or stalled over recent times. The present variation in stillbirth rates across and within high-income countries indicates that further reduction in stillbirth is possible. Large disparities (linked to disadvantage such as poverty) in stillbirth rates need to be addressed by providing more educational opportunities and improving living conditions for women. Placental pathologies and infection associated with preterm birth are linked to a substantial proportion of stillbirths. The proportion of unexplained stillbirths associated with under investigation continues to impede eff orts in stillbirth prevention. Overweight, obesity, and smoking are important modifi able risk factors for stillbirth, and advanced maternal age is also an increasingly prevalent risk factor. Intensifi ed eff orts are needed to ameliorate the eff ects of these factors on stillbirth rates. Culturally appropriate preconception care and quality antenatal care that is accessible to all women has the potential to reduce stillbirth rates in high-income countries. Implementation of national perinatal mortality audit programmes aimed at improving the quality of care could substantially reduce stillbirths. Better data on numbers and causes of stillbirth are needed, and international consensus on defi nition and classifi cation related to stillbirth is a priority. All parents should be off ered a thorough investigation including a high-quality autopsy and placental histopathology. Parent organisations are powerful change agents and could have an important role in raising awareness to prevent stillbirth. Future research must focus on screening and interventions to reduce antepartum stillbirth as a result of placental dysfunction. Identifi cation of ways to reduce maternal overweight and obesity is a high priority for high-income countries.

Lancet, 2011

for The Lancet's Stillbirths Series steering committee* Stillbirth rates in high-income countries declined dramatically from about 1940, but this decline has slowed or stalled over recent times. The present variation in stillbirth rates across and within high-income countries indicates that further reduction in stillbirth is possible. Large disparities (linked to disadvantage such as poverty) in stillbirth rates need to be addressed by providing more educational opportunities and improving living conditions for women. Placental pathologies and infection associated with preterm birth are linked to a substantial proportion of stillbirths. The proportion of unexplained stillbirths associated with under investigation continues to impede eff orts in stillbirth prevention. Overweight, obesity, and smoking are important modifi able risk factors for stillbirth, and advanced maternal age is also an increasingly prevalent risk factor. Intensifi ed eff orts are needed to ameliorate the eff ects of these factors on stillbirth rates. Culturally appropriate preconception care and quality antenatal care that is accessible to all women has the potential to reduce stillbirth rates in high-income countries. Implementation of national perinatal mortality audit programmes aimed at improving the quality of care could substantially reduce stillbirths. Better data on numbers and causes of stillbirth are needed, and international consensus on defi nition and classifi cation related to stillbirth is a priority. All parents should be off ered a thorough investigation including a high-quality autopsy and placental histopathology. Parent organisations are powerful change agents and could have an important role in raising awareness to prevent stillbirth. Future research must focus on screening and interventions to reduce antepartum stillbirth as a result of placental dysfunction. Identifi cation of ways to reduce maternal overweight and obesity is a high priority for high-income countries.

The Lancet, 2016

There were an estimated 2.7 million third trimester stillbirths in 2015 (uncertainty range: 2.5-3.0 million). Stillbirths have reduced more slowly than maternal or child mortality, which were explicitly targeted in the Millennium Development Goals. The Every Newborn Action Plan targets ≤12 stillbirths per 1000 births in every country by 2030. Ninety-two mainly high-income countries have already met this target, although with marked disparities. At least 67 countries, particularly in Africa and conflict affected areas will have to double current progress. Most (98%) stillbirths are in low and middle-income countries. Improved care at birth is essential to prevent 1.3 million intrapartum stillbirths, end preventable maternal and neonatal deaths, and also improve child development. Estimates for stillbirth causation are impeded by multiple classification systems, but for 18 countries with reliable data, congenital abnormalities account for a median of only 7.4%. Many conditions associated with stillbirths are potentially modifiable, and often co-exist such as maternal infections (population attributable fraction (PAF): malaria 8.2%, syphilis 7.7%), non-communicable diseases, nutrition and lifestyle factors (PAF around 10%) and age>35yrs (PAF: 6.7%). Common causal pathways are through impaired placental function, either leading to fetal growth restriction and/or preterm labour, or secondary to prolonged pregnancy (PAF: 14.2%). Two-thirds of newborns have their birth registered. However, less than 5% of neonatal deaths have death registration, and even fewer stillbirths. Recording and registering all facility births, stillbirths, neonatal, and maternal deaths would substantially increase data availability. Improved data alone will not save lives, but provide a tool for targeting interventions to reach >7500 women every day all over the world who experience the reality of stillbirth. Words 266 CONFIDENTIAL-DO NOT PASS ON OR CITE 3 Key messages  What is happening to stillbirth rates? At the end of the Millennium Development Goal (MDG) era there are 2.7 million (uncertainty range: 2.5-3.0 million) third trimester stillbirths annually. Stillbirth rates have declined more slowly since 2000 (Average Annual Rate of Reduction (ARR), 1.8%), than either maternal (ARR=3.4%) or post-neonatal child mortality (ARR=4.5%) which had MDG targets and consequently received more global and country level attention. Better data are essential to accelerate progress towards the target of ≤12 stillbirths per 1000 births in every country by 2030 as outlined in the Every Newborn Action Plan (ENAP), linked to United Nations Secretary General's Every Woman Every Child.  Where to focus? 10 countries account for two-thirds of stillbirths and most neonatal (60%) and maternal (58%) deaths estimated in 2015. Sixty-seven countries need to at least double current progress in reducing stillbirths, many of these in Africa. The highest stillbirth rates (SBR) are in conflict and emergency areas. Over 60% of stillbirths are in rural areas, affecting the poorest families. However, even in the 92 countries with a SBR less than 12 per 1000 marked disparities remain between and within countries.  When and where in the health system to focus? Each year there are an estimated 1.3 million intrapartum stillbirths (deaths during labour), despite two-thirds of births worldwide now being in health facilities. High coverage of good quality care during labour and birth is key, and would also reduce maternal and neonatal deaths, prevent disability and improve child development, giving a high return on investment. Improved quality antenatal care is also important to maximise maternal and fetal well-being, to detect and manage underlying conditions, and to promote healthy behaviours and birth planning.  Which conditions to focus on? There is a myth that most stillbirths are inevitable due to non-preventable congenital abnormalities, yet for countries with reliable data congenital abnormalities account for a median of only 7.4% of stillbirths. Conditions where population attributable fraction (PAF) could be estimated at global level include: maternal age>35yrs (PAF 6.7%), maternal infections (PAF malaria 8.2%, syphilis 7.7%), non-communicable diseases, nutrition and lifestyle factors, many of which co-exist (PAF each around 10%) and prolonged pregnancy (PAF 14.2%). Stillbirths commonly occur via fetal growth restriction and/or preterm labour.  Which data are required for action? Two-thirds of the world's newborns have birth certificate, but death registration coverage is even lower at <5% of neonatal deaths and even fewer stillbirths. Recording and registering all facility births, stillbirths, neonatal deaths, and maternal deaths would substantially increase data availability. Reliable measurement of stillbirths outside facilities using household surveys remains problematic, yet no research is addressing this issue. Little has been invested in improving coverage data for maternal and newborn health interventions including those specific to stillbirths. The ENAP measurement improvement roadmap, includes coverage indicator validation, and development of tools such as a minimum perinatal dataset and perinatal audit, offering opportunities to improve data availability and use.