Comment

Bringing stillbirths out of the shadows

Maternal mortality, stillbirths, and neonatal mortality account for almost 5 million deaths a year and are often analysed separately, despite having overlapping causes and interventions. We propose a comprehensive five-phase mortality transition model to improve analyses of progress and inform strategic planning.

In this empirical data-driven study to develop a model transition, we used UN estimates for 151 countries to assess changes in maternal mortality, stillbirths, and neonatal deaths. On the basis of ratios of maternal to stillbirth and neonatal mortality, we identified five phases of transition, in which phase 1 has the highest mortality and phase 5 has the lowest. We used global databases to examine phase-specific characteristics during 2000–20 for causes of death, fertility rates, abortion policies, health workforce and financing, and socioeconomic indicators. We analysed 326 national surveys to assess service coverage and inequalities by transition phase.

Among 116 countries in phases 1 to 4 in 2000, 73 (63%) progressed at least one phase by 2020, six advanced two phases, and three regressed. The ratio of stillbirth and neonatal deaths to maternal deaths increased from less than 10 in phase 1 to well over 50 in phase 4 and phase 5. Progression was associated with a declining proportion of deaths caused by infectious diseases and peripartum complications, declining total and adolescent fertility rates, changes in health-workforce densities and skills mix (ie, ratio of nurses or midwives to physicians) from phase 3 onwards, increasing per-capita health spending, and reducing shares of out-of-pocket health expenditures. From phase 1 to 5, the median coverage of first antenatal care visits increased from 66% to 98%, four or more antenatal care visits from 44% to 94%, institutional births from 36% to 99%, and caesarean section rates from 2% to 25%. The transition out of high-mortality phases involved a major increase in institutional births, primarily in lower-level health facilities, whereas subsequent progress was characterised by rapid increases in hospital births. Wealth-related inequalities reduced strongly for institutional birth coverage from phase 3 onwards.

The five-phase maternal mortality, stillbirth, and neonatal mortality transition model can be used to benchmark the current indicators in comparison to typical patterns in the transition at national or sub-national level, identify outliers to better assess drivers of progress, and inform strategic planning and investments towards Sustainable Development Goal targets. It can also facilitate programming for integrated strategies to end preventable maternal mortality and neonatal mortality and stillbirths.

Bill & Melinda Gates Foundation.

Early identification of high-risk pregnancies could reduce stillbirths, yet remains a challenge in low- and middle-income countries (LMICs). This study aims to estimate the associations between easily observable risk factors and stillbirths, and construct a risk score which could be adopted in LMICs to identify pregnancies with high risk of stillbirths.

Using the most recent Demographic and Health Surveys from 50 low- and middle-income countries (LMICs) with available data between January 1, 2010 and December 31, 2021, we analysed a total of 22 factors associated with stillbirths in a series of single-adjusted and mutually adjusted logistic regression models. Upon identification of the risk factors with the strongest associations, we constructed a risk score on the basis of the magnitude of the β coefficient to examine the cumulative effects of risk factors on stillbirths. To assess whether the associations between risk scores and stillbirths were moderated by protective factors, we added an interaction term between the identified protective factor and risk scores to the regression model. We also conducted two sets of subgroup analyses for previous history of pregnancy and maternal age at pregnancy and four sets of supplementary analyses to test the robustness of the results.

Among the 795,642 women identified for analysis with at least one pregnancy within the five years before the survey, the most recent pregnancy of 8968 (1.13%) ended as stillbirths. Using a mutually adjusted regression model, we found that the top factors showing the strongest associations with stillbirths were short maternal height (odds ratio [OR]: 1.99, 95% confidence interval [CI]: 1.48–2.67, P < 0.001), interpregnancy interval less than six months (OR: 1.84, 95% CI: 1.42–2.38, P < 0.001), previous stillbirth history (OR: 1.55, 95% CI: 1.07–2.26, P < 0.020), low maternal education (OR: 1.50, 95% CI: 1.01–2.24, P = 0.045), and lowest household wealth (OR: 1.32, 95% CI: 1.08–1.61, P = 0.008). A female household head was a protective factor with an OR of 0.71 (95% CI: 0.55–0.90, P = 0.005). Single-adjusted models, subgroup analyses, and sensitivity analyses showed generally consistent results. We also found that the odds of stillbirths increased with a larger risk score with a P trend <0.001. Compared with women without any risk factors, women with a risk score of 5 or more were 4.11 (95% CI: 2.83–5.97, P < 0.001) times more likely to have their pregnancies ending up as stillbirths. However, these associations were weakened if the head of household was female.

Our study suggested that short maternal height, low socioeconomic status, previous stillbirth history, low maternal education, and very short interpregnancy interval had the strongest associations with stillbirths. The construction of risk scores using easily observable risk factors could be an effective way to identify high-risk pregnancies in resource-poor settings.

This research was supported by Sanming Project of Medicine in Shenzhen (NO. SZSM202111001) and China National Natural Science Foundation (NO. 72203119).

Understanding the sociocultural context and local practices during pregnancy and birth is imperative to identify factors related to perinatal mortality in countries where its burden is high. This study aims to explore the pregnancy and birth related cultural practices and the perceptions of women with a recent perinatal death in Sindh province, Pakistan.

This qualitative exploratory study consisted of in-depth interviews with women who had experienced a perinatal death in the year preceding the study. Women were identified and recruited with the help of lady health workers. After consent, women were interviewed in their homes and in their own language (Sindhi) by a local female interviewer.

Interviews were conducted with women from predominantly rural district of the southern province of Sindh in Pakistan between May and August 2018. The data were coded both inductively and deductively and then analysed using themes.

Twenty-five women were interviewed. Traditional home remedies were commonly used to alleviate pregnancy symptoms such as general aches and pains. The health providers often delayed the information about the perinatal deaths in health facilities, which saddened the women. Most women had fatalistic opinions about what caused their losses, and explained the cause based on their own interpretation, which were not necessarily consistent with known causes of perinatal death. The women also desired to use contraception and believed that it would prevent future pregnancy loss; however, many women were unable to make that decision themselves.

The high use of traditional home-based remedies may be a proxy measure for poor access to formal healthcare services. Many women described poor acknowledgement of their grief which may be harmful. Women’s knowledge about the causes of perinatal mortality in general was very low, improving this knowledge may help women to seek appropriate healthcare services during pregnancy.

Stillbirth is a major public health problem with an enormous mortality burden and psychosocial impact on parents, families and the wider community both globally and in Australia. In 2015, Australia’s late gestation stillbirth rate was over 30% higher than that of the best-performing countries globally, highlighting the urgent need for action. We present an overview of the foundations which led to the establishment of Australia’s NHMRC Centre of Research Excellence in Stillbirth (Stillbirth CRE) in 2017 and highlight key activities in the following areas: Opportunities to expand and improve collaborations between research teams; Supporting the conduct and development of innovative, high quality, collaborative research that incorporates a strong parent voice; Promoting effective translation of research into health policy and/or practice; and the Regional and global work of the Stillbirth CRE. We highlight the first-ever Senate Inquiry into Stillbirth in Australia in 2018. These events ultimately led to the development of a National Stillbirth Action and Implementation Plan for Australia with the aims of reducing stillbirth rates by 20% over the next five years, reducing the disparity in stillbirth rates between advantaged and disadvantaged communities, and improving care for all families who experience this loss.

About 3 million stillbirths occur each year, 98% of which are in low-income and middle-income countries (LMICs). Interpregnancy interval is a key risk factor of interest, because it is modifiable. We aimed to investigate whether there is a causal relationship between the length of interpregnancy interval and risk of subsequent stillbirth.

We used Demographic and Health Surveys (2002–18) from 58 LMICs to study reproductive histories of women and to identify livebirths and stillbirths in the preceding 5 years. Countries were selected on the basis of the availability of interpregnancy interval data and other covariates of interest (age, education, urban or rural residence, and wealth) in surveys done since 2002. Exclusion criteria were being nulliparous, having missing parity data, and not having had at least two births (livebirth or stillbirth) in the 5 years before the survey. We combined two analytic approaches: one that analyses intervals between all births and another that analyses intervals within mothers. We report stratified estimates for the first, second, and third intervals, controlling for all past birth outcomes and intervals in a 5-year period, and other socioeconomic covariates. We also explored effect heterogeneity across key cohort subgroups.

Between July, 1997, and April, 2018, we identified 716 478 births from 338 223 women in 123 Demographic and Health Surveys from 58 LMICs, of which 9647 were stillbirths. Intervals of less than 6 months were associated with an increased risk of stillbirth in the between-mother models when considering the first interval (risk difference [RD] 0·0096, 95% CI 0·008–0·011). This association was slightly attenuated when considering only the second interval (RD 0·0054, 95% CI 0·0010 to 0·0099) and substantially attenuated when considering only the third interval (0·0007, −0·037 to 0·039). Within-mother modelling showed a null association with intervals of 24–59 months when considering the first and second (RD 0·007, 95% CI −0·001 to 0·016) and first and third (0·040, −0·422 to 0·501) intervals.

Although interpregnancy intervals of less than 12 months were associated with increased risk of stillbirth, these effects were attenuated when considering second and third intervals, suggesting the association in the first interval might not be causal. Future studies should use generalisable cohorts with longitudinal data, and report estimates stratified by birth order.

Canadian Institutes of Health Research.