This article is more than 5 years old. Information may no longer be current.

Despite gains, worldwide stillbirth prevention effort still lags behind

Although the number of stillbirths across the world has decreased, an estimated 2.6 million still occur annually, half of them during labor and birth, and most due to preventable conditions, according to a new five-paper series published by The Lancet.

The “Ending Preventable Stillbirths” series details missed opportunities and identifies ways nations may be able to further their progress toward meeting the World Health Assembly’s endorsed target of 12 or fewer stillbirths per 1,000 births in every country by 2030.

“The 2011 Lancet Stillbirths Series reviewed the global status of stillbirths and presented the case for a triple return on investment in stillbirth prevention that also prevents newborn and maternal deaths,” read the series’ executive summary. “… However, despite progress, this new series shows that more must be done to integrate stillbirth prevention within global and national agendas for high quality health care for women, adolescents and babies.”

What has been done, what needs to be done

From 2000 to 2015, the global average stillbirth rate fell from 24.7 per 1,000 total births to 18.4, a 2% annual rate of reduction. Although those figures do represent progress, the series’ authors said the rate of reduction for stillbirths nevertheless falls behind that of maternal (3%) and neonatal (3.1%) mortality, as well as post-neonatal mortality of children younger than 5 years (4.5%).

According to the authors, the international attention toward stillbirths has increased, with more countries adopting the 2014 Every Newborn Action Plan, which includes stillbirth targets for 2030, and setting specific reduction goals. In addition, the availability of country-level stillbirth data has increased, with 38 nations still having no public information on stillbirths in 2015, compared with 68 in 2009.

However, gaps in the data remain, making it difficult to track effective coverage of tested interventions, hindering accountability. In addition, while funding for women’s and children’s health has increased since 2011, only four projects in the entire 12-year funding period, as documented in the Organization for Economic Cooperation and Development, mention stillbirths.

Preventable stillbirths continue to occur, caused by maternal infections, noncommunicable diseases and obstetric complications. In high-income countries, 90% of stillbirths occur in the antepartum period, and are often associated with lifestyle factors such as obesity and smoking. Improved antenatal care, family planning and poverty alleviation can reduce these risk factors, the authors said.

Global burden

Although 94 countries have cleared the bar set by the World Health Assembly, most of them are predominantly high- and middle-income, with noticeable disparities within individual nations. Even among high-income countries, stillbirth rates at the third trimester, can range from Iceland’s 1.3 to Ukraine’s 8.8 per 1,000 births.

At least 56 countries, particularly in Africa and conflict-affected areas, will have to at least double their current pace to reach the target. According to the series’ authors, 98% of the 2.6 million annual stillbirths occur in low- and middle-income countries, with 75% of them in sub-Saharan Africa and south Asia.

“At present rates of progress, more than 160 years will pass before a pregnant woman in Africa has the same chance of her baby being born alive as a woman in a high-income country today,” read the executive summary.

Stigma, cost and bereavement

In a survey conducted for the series, 3,503 parents who suffered a stillbirth reported that their community felt “parents should try to forget their stillborn baby and have another child.” Parents often suppress their grief in public, and women whose babies have been stillborn are particularly stigmatized, and even sometimes become victims of violence.

Negative psychological symptoms are also common in bereaved parents, and can persist years after the death of the baby. According to the authors, an estimated 4.2 million women have depression associated with stillbirth. There is also a direct financial cost, which is often 10% to 70% greater than the cost of a livebirth, as parents typically must pay for funeral, burial or cremation arrangements. Parents often lose income from time taken off from work.

The authors recommend that immediate and respectful bereavement care be part of routine practice for all health care professionals. Allowing women to see and hold their babies and create memories, has been shown to help in maximizing the parents’ wellbeing, they wrote.

Further reducing stillbirths

The series identifies five priority actions the authors believe could further accelerate the worldwide reduction of stillbirths. They are:

• Intentional leadership, especially from policy makers, which the authors identified has the biggest challenge;
• giving the bereaved, especially women, a larger voice;
• implementation of integrated interventions with commensurate investment;
• creation of indicators to measure effect of interventions, and especially to monitor program progress and quality of care; and
• investigating crucial knowledge gaps.

“Strong leadership is needed worldwide and at the level of countries and institutions with a mandate to lead global efforts for mothers and their babies,” read the executive summary. “[The United Nations] and other global groups must seize leadership opportunities and include stillbirths in their daily work, as this responsibility is part of their mission.” – by Jason Laday

Additional information:

http://www.thelancet.com/series/ending-preventable-stillbirths