SeriesStillbirths: Where? When? Why? How to make the data count?
Section snippets
Why don't stillbirths count?
Stillbirths are invisible in many societies and on the worldwide policy agenda, but are very real to families who experience a death. Despite 30 years of attention to child survival interventions,1, 2 more than 20 years of attention to safe motherhood,3, 4 and increasing recent attention to survival of newborn babies,5, 6, 7 the focus worldwide has remained on survival after livebirth. Stillbirths remain mostly ignored, not counting on policy, programme, and investment agendas, both
Defining stillbirths
Inconsistent use of terminology has contributed to confusion about stillbirths.8 The terminology has changed over time and, despite clear worldwide guidelines, there is much variation between countries, with greater variability in high-income countries than in low-income countries.22, 23
The International Classification of Diseases, 10th revision (ICD-10)24 refers to fetal deaths, not stillbirths. Fetal death is defined as “death prior to the complete expulsion or extraction from its mother of a
Where do the numbers come from?
In 1983, WHO published a worldwide estimate of 8 million perinatal deaths,35 and in 1996 WHO released perinatal mortality estimates with a rate of 58 per 1000 total births in developing countries and a stillbirth rate of 32 per 1000 total births, suggesting 4·3 million stillbirths worldwide.36 Although a literature review of stillbirth rates was published in 2006,37 up to that point, no country-specific rates or numbers of stillbirths had been recorded, impeding visibility and action.
In 2006,
Regional and national variation
In 2008, a worldwide total of 2·65 million (uncertainty range 2·08 million to 3·79 million) stillbirths was estimated.38 98% of these third-trimester stillbirths were in low-income and middle-income countries, and more than three-quarters were in south Asia and sub-Saharan Africa (table 1).
Variation in stillbirth rates among countries is substantial. In high-income countries, the third-trimester stillbirth rate is less than four per 1000 total births (uncertainty range 35 500–38 000), a quarter
When do stillbirths occur?
A practical grouping of stillbirths is by time of death: antepartum (before the onset of labour) or intrapartum (during labour and birth; figure 1). The worldwide intrapartum stillbirth estimates we provide here are based on similar methods to previous country estimates,50 with use of median regional intrapartum stillbirth percentages. The panel details the inputs (94 datasets, webappendix pp 1–4), methods, and limitations of these estimates. A sensitivity analysis of 53 datasets with a
Why do stillbirths occur?
To reduce the numbers of stillbirths, basic information on causation is crucial.8 National neonatal cause-of-death estimates have been published,7, 53 are regularly updated through the UN,40 and disseminated by Countdown to 2015 national data profiles. This process has helped to focus on the three major causes of neonatal death (infections, intrapartum-related causes, and preterm birth complications).39 National estimates of stillbirth causes do not exist. Two fundamental challenges must be
Trends and predicting progress to 2020
New estimates of stillbirth trends from 1995 to 200938 suggest that the average worldwide yearly rate of reduction of stillbirths has reduced by 1·1%, which is lower than the reduction for mortality in children younger than 5 years (2·3%)9 and is less than that for maternal mortality reduction at 1·3% (1990–200873), 2·5% (1990–200574), or 2·1% (1990–200841). The slowest decline is seen in sub-Saharan Africa and South Asia, with almost no change in sub-Saharan Africa since 2000 (figure 5). This
Improving stillbirth rate estimation
Exercises to estimate worldwide third-trimester stillbirth rates are important for worldwide policy and programme prioritisation, but do not address the urgent need for high-quality, recent data at country level. Although there is no doubt that stillbirths are a large problem, much of our information depends on estimates and focuses on third-trimester stillbirths. Present estimates are likely to be an underestimate, particularly in the highest mortality settings for which the data are sparse.
How to reduce numbers of stillbirths
More reliable data are essential to enhance the effectiveness of health systems to monitor both implementation and effect on stillbirths. Ignoring stillbirths is a missed opportunity to measure effect of programmes for maternal, neonatal, and fetal health. Many of the 350 000 maternal deaths every year are associated with lack of effective intrapartum care. Intrapartum stillbirth rates have been proposed as a measure of quality of intrapartum care79 and are an important indicator of quality,
Research priorities for stillbirth epidemiology
Only 3% of publications on stillbirths were identified to be related to low-income countries in one review,25 although these countries accounted for almost 90% of the burden. This gap is greater than the 10/90 gap for worldwide health research, whereby only 10% of research addresses 90% of the burden.99 Additionally, there are missed opportunities to include stillbirth outcomes in related studies. In an analysis of Cochrane reviews,54 apart from trials on cervical cerclage, only a few pregnancy
Conclusions
Two clear messages resound. First, there are now sufficient data to justify urgent attention and action to reduce this large burden of 2·65 million stillbirths in the last 12 weeks of pregnancy,38 linked to about 3 million early neonatal deaths and 350 000 maternal deaths.7 Stillbirths remain invisible on programmatic and policy priorities and yet are highly relevant to existing investments for maternal and neonatal health, especially for care at the time of birth when a combined 2 million
References (103)
- et al.
Where and why are 10 million children dying every year?
Lancet
(2003) - et al.
30 years after Alma-Ata: has primary health care worked in countries?
Lancet
(2008) - et al.
Maternal mortality: who, when, where, and why
Lancet
(2006) - et al.
Maternal mortality—a neglected tragedy. Where is the M in MCH?
Lancet
(1985) Issue attention in global health: the case of newborn survival
Lancet
(2010)- et al.
Systematic scaling up of neonatal care in countries
Lancet
(2005) - et al.
4 million neonatal deaths: When? Where? Why?
Lancet
(2005) - et al.
Neonatal, postneonatal, childhood, and under-5 mortality for 187 countries, 1970–2010: a systematic analysis of progress towards Millennium Development Goal 4
Lancet
(2010) - et al.
Stillbirth
Lancet
(2007) - et al.
SBRs: delivering estimates in 190 countries
Lancet
(2006)
The availability of perinatal health indicators in Europe
Eur J Obstet Gynecol Reprod Biol
Reducing intrapartum stillbirths and intrapartum-related neonatal deaths
Int J Gynaecol Obstet
3.6 million neonatal deaths—what is progressing and what is not?
Semin Perinatol
Global, regional, and national causes of child mortality in 2008: a systematic analysis
Lancet
Effect of home-based neonatal care and management of sepsis on neonatal mortality: field trial in rural India
Lancet
Two years prospective study of perinatal mortality in Jos, Nigeria
Int J Gynaecol Obstet
The postpartum period: the key to maternal mortality
Int J Gynaecol Obstet
Risk factors for sudden intrauterine unexplained death: epidemiologic characteristics of singleton cases in Oslo, Norway, 1986–1995
Am J Obstet Gynecol
Determinants of unexplained antepartum fetal deaths
Obstet Gynecol
Infection-related stillbirths
Lancet
Perinatal mortality audit: counting, accountability, and overcoming challenges in scaling up in low- and middle-income countries
Int J Gynaecol Obstet
Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5
Lancet
Estimates of maternal mortality worldwide between 1990 and 2005: an assessment of available data
Lancet
The way forward
Lancet
Interim measures for meeting needs for health sector data: births, deaths, and causes of death
Lancet
New indicator of quality of emergency obstetric and newborn care
Lancet
Delivery of MDG 5 by active management with data
Lancet
Skilled birth attendant competence: an initial assessment in four countries, and implications for the Safe Motherhood movement
Int J Gynaecol Obstet
Stillbirths: why they matter
Lancet
Analysis of perinatal mortality and its components: time for a change?
Am J Epidemiol
A comparison of foetal and infant mortality in the United States and Canada
Int J Epidemiol
Fetal and perinatal mortality, United States, 2005
Natl Vital Stat Rep
Perinatal mortality 2008
Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis
Lancet
Perinatal and neonatal mortality for the year 2000: country, regional and global estimates
Generating political priority for safe motherhood
Afr J Reprod Health
Countdown to 2015: assessment of official development assistance to maternal, newborn, and child health, 2003–08
Lancet
Stillbirths: what difference can we make and at what cost?
Lancet
Stillbirths: how can health systems deliver for mothers and babies?
Lancet
Long-term trends in fetal mortality: implications for developing countries
Bull World Health Organ
International statistical classification of diseases and related health problems: tenth revision, volume 2: instruction manual
Making stillbirths count, making numbers talk—issues in data collection for stillbirths
BMC Pregnancy Childbirth
Neonatal mortality of low-birth-weight infants in Bangladesh
Bull World Health Organ
‘Kangaroo mother care’ to prevent neonatal deaths due to preterm birth complications
Int J Epidemiol
The EPICure study: growth and associated problems in children born at 25 weeks of gestational age or less
Arch Dis Child Fetal Neonatal Ed
The EPICure study: outcomes to discharge from hospital for infants born at the threshold of viability
Pediatrics
EPICure: facts and figures: why preterm labour should be treated
BJOG
Nuffield Council on Bioethics, 2006
Perinatal health monitoring in Europe: results from the EURO-PERISTAT project
Inform Health Soc Care
Cited by (0)
- ‡
Members listed at end of paper