The Lancet today launches its Series on Stillbirths, with the very latest data showing that more than 2.6 million stillbirths occur each year—at least 7,000 each day. While 98% of these occur in low-income and middle-income countries, stillbirths also continue to blight wealthy nations, with around 1 in every 320 babies stillborn in high-income countries. The Series addresses stillbirth rates and causes in all countries, and sets key actions by 2020 to halve this event that devastates parents and families. The international team of authors* is led by Dr Joy Lawn (Saving Newborn Lives/Save the Children, Cape Town, South Africa) and Vicki Flenady, Mater Medical Research Institute and University of Queensland, Australia and Chair of the International Stillbirth Alliance (ISA). The Series involves 69 authors, from more than 50 organisations and 18 countries, who have worked for over 2 years on the analysis. The work was primarily funded by the Bill and Melinda Gates Foundation.
The Series includes 6 papers, two further research Articles, and 8 Comments including one from bereaved parents and one from professional organisations responsible for clinical care to reduce stillbirths.
The global picture
Around 2.6 million stillbirths occur worldwide each year during the last trimester of pregnancy (after 28 weeks' gestation). This is the WHO definition for stillbirths for international comparison since different countries use different cut offs. Most high-income countries count stillbirths around 22 weeks' gestation and if this definition was used worldwide the total number of global stillbirths would be about 45% higher. Using the 22 week cut-off point for stillbirths in high-income countries changes the risk of stillbirth from 1 in 320 babies (3.1 per 1000) to 1 in 200 (5 per 1000) in those countries.
Joy Lawn and colleagues explore the implications of the first ever set of nationally reviewed stillbirth estimates undertaken with the WHO (paper 2). Rates of stillbirths range from 2.0 per 1000 total births in Finland to more than 40 per 1000 in Nigeria and Pakistan. In 2009, 98% of all stillbirths were in low-income and middle-income countries and more than three quarters (76%) occurred in south Asia and sub-Saharan Africa. Most high-income countries have rates less than 5 per 1000, while high burden countries have rates of 25 or more per 1000; if these highest-burden countries had rates of the same as rich nations, more than three quarters of the world's annual stillbirths would be prevented.
Approximately 1.2 million stillbirths occur during birth (intrapartum) and 1.4 million before birth (antepartum). Most intrapartum stillbirths are associated with obstetric emergencies (childbirth complications) and these deaths have been virtually eliminated in high-income countries. Antepartum stillbirths are more commonly associated with maternal infections and fetal growth restriction. For example syphilis is a highly preventable cause of stillbirth, still common in some countries. In high-income countries, obesity, smoking, and advanced maternal age are among the big risk factors.
Stillbirth rate data, estimates, and the first ever time trend analysis are discussed in one of the Articles by Simon Cousens, Joy Lawn and colleagues including from WHO. Overall, stillbirths have fallen from an estimated 3.03 million in 1995 to 2.64 million in 2009.The global stillbirth rate has been reduced from 22 stillbirths per 1000 total births down to 19. Analyses suggest that stillbirths have decreased by 1.1% per year since 1995, lower than the 2.3% annual reduction in child under-5 mortality and 2.5% annual reduction in maternal mortality. In some, but not all, high-income countries the rate of progress has slowed (see linked spreadsheet for individual country rates, rankings, and absolute numbers of stillbirths). The three countries with the most progress in terms of reduction in stillbirths rates from 1995 to 2009 are Colombia, China and Mexico.
Rates vary within countries, with rates in India varying from 20 to 66 per 1000 total births in different states. In high-income countries, women from disadvantaged backgrounds are much more likely to have a stillbirth, with black women in the UK, African-American women in US and Indigenous women in Australia and Canada around twice as likely as white women to experience a stillbirth—as are other women living with socioeconomic deprivation compared with those who don't.
The Series also addresses common misconceptions, such as that stillbirth is an inevitable loss that cannot be prevented—the reality being that congenital abnormalities cause less than 5% of total global stillbirths. The fact that the risk of stillbirth increases throughout the final trimester of pregnancy (3 times greater at 40 weeks than at earlier gestational ages) is largely unrecognised.
Dr Frederik Frøen, Norwegian Institute of Public Health, and colleagues (paper 1) say that socio-political leaders, and others with power to create awareness to prevent stillbirths, have not done so. Stillbirths are not part of the Millennium Development Goals (MDGs) and are invisible in most global and national policy and programme strategies.
Frøen and colleagues add that it is women who experience stillbirth that suffer the most, facing stigma such as perceived failure as a mother, as well being at high risk of depression, anxiety, and post-traumatic stress disorder. Despite the worldwide attention given in recent years to maternal, newborn and child health (MNCH), stillbirths remain neglected on the world stage and do not feature in MNCH policies, as well as not featuring in MDGs. This is despite the fact that the numbers of third trimester stillbirths are more than AIDS deaths and malaria deaths combined.
The authors of paper 1 further discuss that in society, stillbirths remain largely hidden. Even in wealthy nations, acknowledgment of parent's grief after a stillbirth is a recent phenomenon. In poorer settings, bereavement rituals for a stillbirth are a rarity. A survey of health-care professionals and parents in 135 countries showed that most stillborn babies are disposed of without recognition or rituals, such as naming, funeral rites, or the mother holding or dressing the baby.
Yet there are effective interventions that can make big inroads into stillbirth mortality. For low-income and middle-income countries, these are detailed in the third paper (Prof Zulfiqar Bhutta and colleagues), with 10 interventions highlighted that, with 99% coverage, would reduce stillbirths by around half. The fourth paper (Prof Robert Pattinson and colleagues) shows that universal access to these same interventions would also prevent millions of neonatal and maternal deaths, at a very affordable additional running cost of US$ 2.32 per person per year, which also includes a further 5 interventions specific to mothers and newborn children. The fifth paper (Vicki Flenady and colleagues) digs deeper into the patchy progress in high-income countries and the need to close gaps in equity and quality of care.
Vision for 2020
The Series concludes with a vision for 2020 (paper 6: Prof Robert L Goldenberg and colleagues), including a target for all countries with a current stillbirth rate less than 5 per 1000 to eliminate all preventable stillbirths and for all countries with a rate over 5 to reduce their stillbirth burden by at least 50%. The Series authors conclude: "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."
The paper asks the international community to: include stillbirth reduction in all relevant maternal/neonatal programmes, include it in all relevant international reports; report accurate stillbirth rates and cause of death data, create a universal classification system, and implement an effective business model for reducing stillbirths.
Individual countries are asked to create a stillbirth reduction plan, collect accurate data, assess disparities in stillbirth rates by ethnic origin and location, audit stillbirths for causes and preventability measures, and reduce stigma associated with stillbirth.
Communities and families are asked to: ensure empowerment for women and families, set up pregnancy improvement committees, provide birth plans and transportation, reduce stigma, and provide bereavement support.
Finally, support for research and research capacity must be increased, with stillbirth included as an outcome in all relevant research.
Note to editors: *This Series of papers represents the culmination of a collaborative effort between a wider team coordinated by The Lancet's Stillbirths Series steering committee: J Frederik Frøen (Norwegian Institute of Public Health, Oslo, Norway, and International Stillbirth Alliance); Joy E Lawn (Saving Newborn Lives/Save the Children, Cape Town, South Africa); Zulfiqar A Bhutta (Division of Women and Child Health, Aga Khan University, Karachi, Pakistan); Robert Pattinson (Medical Research Council and University of Pretoria, South Africa); Vicki Flenady (International Stillbirth Alliance and Mater Medical Research Institute, Brisbane, QLD, Australia); Robert L Goldenberg (Department of Obstetrics and Gynecology, Drexel University, Philadelphia, PA, USA); and Monir Islam (Family Health and Research, World Health Organization Regional Office for South-East Asia).
For Executive Summary, see: http://press.thelancet.com/sbsexec.pdf
If you wish to provide a link to the Stillbirths Series for your readers, please use www.thelancet.com/series/stillbirth (note all papers will be free to download but the link will not work until the embargo lifts)
For Series paper 1 (Stillbirths, why they matter) see: http://press.thelancet.com/sbs1.pdf
Contact for paper 1: Dr J Frederik Frøen, Norwegian Institute of Public Health, Oslo, Norway. T) +47 92 49 34 35. E) email@example.com
For Series paper 2, (Stillbirths, where, when, why?) see: http://press.thelancet.com/sbs2.pdf
Contact for paper 2: Dr Joy Lawn, Saving Newborn Lives and Save the Children, Cape Town, South Africa. T) 11th-13th April +44 7989 528 724; From 14th April +27 21 532 3494, +27 798 839 706. E) firstname.lastname@example.org
For Series paper 3 (What can we do at what cost) see: http://press.thelancet.com/sbs3.pdf
Contact for paper 3: Professor Zulfiqar A Bhutta, Aga Khan University, Karachi, Pakistan. T) +92 300 823 6813. E) email@example.com
For Series paper 4 (How can health systems deliver) see: http://press.thelancet.com/sbs4.pdf
Contact for paper 4: Professor Robert Pattinson, MRC Maternal and Infant Health Care Strategies Research Unit, University of Pretoria, South Africa. T) 11th-14th April +27 83 306 5494 (running a workshop in Bloemfontein); From 15th April +27 12 373 1002, +27 83 306 5494. E) Robert.firstname.lastname@example.org (note Joy Lawn can also answer questions on paper 4)
For Series paper 5: (High income countries) see: http://press.thelancet.com/sbs5.pdf
Contact for paper 5: Vicki Flenady, Mater Medical Research Institute and University of Queensland, Australia and International Stillbirth Alliance. T) +61 419 664 956. E) Vicki.Flenady@mater.org.au
For Series paper 6: (vision for 2020) see: http://press.thelancet.com/sbs6.pdf
Contact for paper 6: Professor Robert Goldenberg, Department of Obstetrics and Gynecology, Drexel University, Philadelphia, PA, USA. T) +1 215 762 2014 / +1 215 206 5733. E) email@example.com
For Article 'National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995, a systematic analysis' (S Cousens, J Lawn & colleagues) see: http://press.thelancet.com/sbsr1.pdf
For Article 'Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis' (V Flenady, L Koopmans & colleagues) see: http://press.thelancet.com/sbsr2.pdf
For Comments with the Series see: http://press.thelancet.com/sbscomment.pdf
Comment contacts: Janet Scott, Sands, London, UK. T) +44 (0) 7554 454313 E) firstname.lastname@example.org
The Lancet Press Office. T) +44 (0) 20 7424 4949 E) email@example.com