Elsevier

The Lancet

Volume 377, Issue 9775, 23–29 April 2011, Pages 1448-1463
The Lancet

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

https://doi.org/10.1016/S0140-6736(10)62187-3Get rights and content

Summary

Despite increasing attention and investment for maternal, neonatal, and child health, stillbirths remain invisible—not counted in the Millennium Development Goals, nor tracked by the UN, nor in the Global Burden of Disease metrics. At least 2·65 million stillbirths (uncertainty range 2·08 million to 3·79 million) were estimated worldwide in 2008 (≥1000 g birthweight or ≥28 weeks of gestation). 98% of stillbirths occur in low-income and middle-income countries, and numbers vary from 2·0 per 1000 total births in Finland to more than 40 per 1000 total births in Nigeria and Pakistan. Worldwide, 67% of stillbirths occur in rural families, 55% in rural sub-Saharan Africa and south Asia, where skilled birth attendance and caesarean sections are much lower than that for urban births. In total, an estimated 1·19 million (range 0·82 million to 1·97 million) intrapartum stillbirths occur yearly. Most intrapartum stillbirths are associated with obstetric emergencies, whereas antepartum stillbirths are associated with maternal infections and fetal growth restriction. National estimates of causes of stillbirths are scarce, and multiple (>35) classification systems impede international comparison. Immediate data improvements are feasible through household surveys and facility audit, and improvements in vital registration, including specific perinatal certificates and revised International Classification of Disease codes, are needed. A simple, programme-relevant stillbirth classification that can be used with verbal autopsy would provide a basis for comparable national estimates. A new focus on all deaths around the time of birth is crucial to inform programmatic investment.

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

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