Stillbirths: progress and unfinished business

Lancet, 2011

Stillbirth is a common adverse pregnancy outcome, with nearly 3 million third-trimester stillbirths occurring worldwide each year. 98% occur in low-income and middle-income countries, and more than 1 million stillbirths occur in the intrapartum period, despite many being preventable. Nevertheless, stillbirth is practically unrecognised as a public health issue and few data are reported. In this fi nal paper in the Stillbirths Series, we call for inclusion of stillbirth as a recognised outcome in all relevant international health reports and initiatives. We ask every country to develop and implement a plan to improve maternal and neonatal health that includes a reduction in stillbirths, and to count stillbirths in their vital statistics and other health outcome surveillance systems. We also ask for increased investment in stillbirth-related research, and especially research aimed at identifying and addressing barriers to the aversion of stillbirths within the maternal and neonatal health systems of low-income and middle-income countries. Finally, we ask all those interested in reducing stillbirths to join with advocates for the improvement of other pregnancy-related outcomes, for mothers and their off spring, so that a united front for improved pregnancy and neonatal care for all will become a reality.

Archives of disease in childhood, 2015

Remarkable advances have been made over the past decade in defining the burden of newborn mortality and morbidity and stillbirths, and in identifying interventions to address the major risk factors and causes of deaths. However, progress in saving newborn lives and preventing stillbirths in countries lags behind that for maternal mortality and for children aged 1-59 months. To accelerate progress, greater focus is needed on improving coverage, quality and equity of care at birth -particularly obstetric care during labour and childbirth, and care for small and sick newborns, which gives a triple return on investment, reducing maternal and newborn lives as well as stillbirths. Securing nationallevel political priority for newborn health and survival and stillbirths, and implementation of the Every Newborn Action Plan are critical to accomplishing the unfinished global agenda for newborns and stillbirths beyond 2015.

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.

EE orts to achieve the new worldwide goals for maternal and child survival will also prevent stillbirth and improve health and developmental outcomes. However, the number of annual stillbirths remains unchanged since 2011 and is unacceptably high: an estimated 2·6 million in 2015. Failure to consistently include global targets or indicators for stillbirth in post-2015 initiatives shows that stillbirths are hidden in the worldwide agenda. This Series paper summarises fi ndings from previous papers in this Series, presents new analyses, and proposes specifi c criteria for successful integration of stillbirths into post-2015 initiatives for women's and children's health. Five priority areas to change the stillbirth trend include intentional leadership; increased voice, especially of women; implementation of integrated interventions with commensurate investment; indicators to measure ee ect of interventions and especially to monitor progress; and investigation into crucial knowledge gaps. The post-2015 agenda represents opportunities for all stakeholders to act together to end all preventable deaths, including stillbirths.

The Lancet, 2016

The number of annual stillbirths remains unchanged and unacceptably high, 2.7 million in 2015. Efforts to achieve the new global goals for maternal and child survival will also prevent stillbirth and improve health and developmental outcomes. However, failure to consistently include global targets or indictors for stillbirth in post-2015 initiatives shows this issue remains hidden in the global agenda. This paper summarises findings from previous papers in this Series, presents new analyses, and proposes specific criteria for successful integration of stillbirths into post-2015 initiatives for women's and children's health. Five priority areas to "change the curve" include: (1) intentional leadership; (2) increased voice, especially of women; (3) implementation of integrated interventions with commensurate investment; (4) indicators to measure impact and especially to monitor progress; and (5) investigation of critical knowledge gaps. The post-2015 agenda represents opportunities for all stakeholders to act together to end all preventable deaths including stillbirths.

BJOG: An International Journal of Obstetrics & Gynaecology

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

Worldwide, 2·65 million (uncertainty range 2·08 million to 3·79 million) stillbirths occur yearly, of which 98% occur in countries of low and middle income. Despite the fact that more than 45% of the global burden of stillbirths occur intrapartum, the perception is that little is known about eff ective interventions, especially those that can be implemented in low-resource settings. We undertook a systematic review of randomised trials and observational studies of interventions which could reduce the burden of stillbirths, particularly in low-income and middle-income countries. We identifi ed several interventions with suffi cient evidence to recommend implementation in health systems, including periconceptional folic acid supplementation or fortifi cation, prevention of malaria, and improved detection and management of syphilis during pregnancy in endemic areas. Basic and comprehensive emergency obstetric care were identifi ed as key eff ective interventions to reduce intrapartum stillbirths. Broad-scale implementation of intervention packages across 68 countries listed as priorities in the Countdown to 2015 report could avert up to 45% of stillbirths according to a model generated from the Lives Saved Tool. The overall costs for these interventions are within the general estimates of cost-eff ective interventions for maternal care, especially in view of the eff ects on outcomes across maternal, fetal, and neonatal health.

Variation in stillbirth rates across high-income countries and large equity gaps within high-income countries persist. If all high-income countries achieved stillbirth rates equal to the best performing countries, 19 439 late gestation (28 weeks or more) stillbirths could have been avoided in 2015. The proportion of unexplained stillbirths is high and can be addressed through improvements in data collection, investigation, and classification, and with a better understanding of causal pathways. Substandard care contributes to 20–30% of all stillbirths and the contribution is even higher for late gestation intrapartum stillbirths. National perinatal mortality audit programmes need to be implemented in all high-income countries. The need to reduce stigma and fatalism related to stillbirth and to improve bereavement care are also clear, persisting priorities for action. In high-income countries, a woman living under adverse socioeconomic circumstances has twice the risk of having a stillborn child when compared to her more advantaged counterparts. Programmes at community and country level need to improve health in disadvantaged families to address these inequities.

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 ...