Stillbirths: The invisible public health problem

Every day more than 7,300 babies are stillborn. A death occurs just when parents expect to welcome a new life.

Ninety-eight percent of stillbirths occur in low and middle-income countries. Wealthier nations are not immune with 1 in 200 pregnancies resulting in a stillbirth -- two thirds occurring in the last trimester of pregnancy, a rate that has stagnated in the last decade.

The five main causes of stillbirths are childbirth complications, maternal infections in pregnancy, maternal disorders (especially pre-eclampsia and diabetes), fetal growth restriction and congenital abnormalities.

The number of stillbirths worldwide has declined by only 1.1 percent per year, from 3 million per year in 1995 to 2.6 million in 2009. This is slower than reductions for child and maternal mortality.

"Stillbirths often go unrecorded, and are not seen as a major public health problem," says Flavia Bustreo, M.D., Assistant Director-General for Family and Community Health at the World Health Organization. "Yet, stillbirth is a heartbreaking loss for women and families. We need to acknowledge these losses and do everything we can to prevent them."

If all causes of stillbirth are taken together, the new estimates would place stillbirths fifth on the list of causes of deaths worldwide, according to The Lancet's Stillbirths Series, authored by 69 experts from more than 50 organizations in 18 countries. The Series is composed of six scientific papers, two research articles, and eight linked comments.

Joy Lawn, M.D., PhD, Director of Global Evidence and Policy, Saving Newborn Lives/Save the Children, a lead author of The Lancet's Stillbirths Series who coordinated the new estimates, emphasizes that "almost no burden affecting families is so big and yet so invisible both in society and on the global public health agenda."

The number of stillbirths can be slashed, say most experts. "Stillbirths need to be an integral part of the maternal, newborn and child health agenda," says Carole Presern, PhD, Director of The Partnership for Maternal, Newborn & Child Health (PMNCH) and a midwife. "We do know how to prevent most of them."

Besides lacking visibility, stillbirths lack leadership both locally and internationally. "Parental groups must join with professional organizations to bring a unified message on stillbirths to government agencies and the UN," says J. Frederik Frøen, M.D., PhD, an epidemiologist at The Norwegian Institute of Public Health and member of the International Stillbirth Alliance.

Stillbirths -- the new estimates in detail

Almost half of stillbirths, 1.2 million, happen when the woman is in labor. These deaths are directly related to the lack of skilled care at this critical time for mothers and babies. Before-labor stillbirths account for 1.4 million deaths.

"An African woman has a 24 times higher chance of having a stillbirth at the time of delivery than a woman in a high-income country," says Vicki Flenady, a perinatal epidemiologist, Chair of the International Stillbirth Alliance, and author of the paper on stillbirths in high-income countries for The Lancet's Stillbirths Series.

Two-thirds of stillbirths happen in rural areas, where skilled birth attendants, in particular midwives and physicians, are not always available for essential care during childbirth and for obstetric emergencies, including caesarean sections.

The stillbirth rate varies sharply by country, from the lowest rates of 2 per 1,000 births in Finland and Singapore and 2.2 per 1,000 births in Denmark and Norway, to highs of 47 in Pakistan and 42 in Nigeria, 36 in Bangladesh, and 34 in Djibouti and Senegal.

It is estimated that some 1.8 million stillbirths occur in ten countries -- India, Pakistan, Nigeria, China, Bangladesh, Democratic Republic of the Congo, Ethiopia, Indonesia, Afghanistan and United Republic of Tanzania. Half of all stillbirths occur in India, Pakistan, Nigeria, China and Bangladesh alone. These same countries account for a high number of maternal and newborn deaths.

Rates also vary widely within countries. In India, rates range from 20 to 66 per 1,000 births in different states. In high-income countries, disadvantaged women still have very high stillbirth rates. For example, indigenous women in Canada and Australia have stillbirth rates equal to women living in some low and middle-income countries.

Comparing 1995 to 2009 stillbirth rates, the smallest declines were reported in Sub-Saharan Africa and Oceania. Significant declines are reported for China, Bangladesh, and India, which had a combined estimate of 400,000 fewer stillbirths in 2009 than in 1995.

"Stillbirth rates have halved in China and Mexico since 1995, demonstrating what can be accomplished in middle-income countries," says Dr. Lawn.

Well-known interventions for women and babies would also reduce stillbirths

"This Series shows that the way to address the problem of stillbirth is to strengthen existing maternal, newborn, and child health programs by focusing on key interventions, which often overlap with those interventions that benefit mothers and neonates," says Gary L. Darmstadt, M.D., Director, Family Health Division, Global Health Program, Bill & Melinda Gates Foundation.

According to The Lancet's Stillbirths Series, as many as 1.1 million stillbirths could be averted with universal coverage of the following interventions:

• Comprehensive emergency obstetric care 696,000
• Syphilis detection and treatment 136 000
• Detection and management of fetal growth restriction 107,000
• Detection and management of hypertension during pregnancy 57,000
• Identification and induction for mothers with >41 weeks gestation 52,000
• Malaria prevention, including bednets and drugs 35,000
• Folic acid fortification before conception 27,000
• Detection and management of diabetes in pregnancy 24,000

"An additional 1.6 million deaths of mothers and newborns could be averted if you add five additional interventions beyond stillbirth interventions, such as antenatal steroids and neonatal resuscitation," says Professor Zulfiqar A. Bhutta, M.D., PhD, Chair, Department of Pediatrics and Child Health, The Aga Khan University, Pakistan. "This is all highly doable and would save 2.7 million lives -- a massive achievement."

Such interventions could be provided to all women everywhere at an overall cost of US$10.9 billion per year, or $2.32 per person in the 68 highest burden countries, according to the economic analysis by The Series team.

"This would provide a triple return for every dollar invested since these interventions can prevent stillbirths as well as save mothers and newborns, " explains Robert Pattinson, M.D. of South Africa's Medical Research Council, one of the team who developed the analysis using the Lives Saved Tool modelling.

If all women gave birth in health facilities offering high-quality, comprehensive emergency obstetric care, almost 700,000 stillbirths, 170,000 maternal deaths and nearly 600,000 neonatal deaths could be averted.

"Ultimately, there's a direct correlation between greatly increased coverage of these interventions and the numbers of deaths averted," says Carole Presern of PMNCH.

New funds

In September 2010, UN Secretary-General Ban Ki-moon announced the Global Strategy for Women's and Children's Health, aimed at saving 16 million mothers and children over the next five years.

The initiative has drawn pledges totalling $40 billion in commitments from governments, foundations, corporations and non-governmental organizations.

Besides the new funding, a special session on non-communicable diseases will be held at the UN General Assembly this September. Two important topics connected to stillbirths will be discussed: gestational diabetes (diabetes during pregnancy) and hypertension (high blood pressure). Both these conditions are common in pregnant women in high-income countries.

Stillbirth stigma persists

In many parts of the world, taboos and evil spirits are held responsible or the woman is blamed for the loss of a child.

Women who experience stillbirth suffer the most because of the stigma attached to it and their perceived failure as a mother. Often they suffer depression, anxiety, and post-traumatic stress.

"By shining a spotlight on the tragic toll of stillbirths, we can prevent stigma, relieve suffering and make greater progress to improve the health of every woman and every newborn," says Purnima Mane, Deputy Executive Director of United Nations Population Fund.

Stillbirths are overlooked

Despite the large numbers, stillbirths have been relatively overlooked as a global public health problem. They are not included in the Millennium Development Goals for maternal and child health set by the United Nations.

"WHO has taken the unprecedented step of working together with The Lancet's Stillbirths Series team to develop the first comprehensive, global set of stillbirth estimates by country," reports Dr. Bustreo.

These estimates underpin the Series analysis and will be included, for the first time, in WHO's World Health Statistics report for 2011. In addition to Dr. Lawn and WHO researchers, Simon Cousens, Professor of Epidemiology and Medical Statistics at the London School of Hygiene and Tropical Medicine, worked on the analysis for the new estimates.

Authors of The Lancet's Stillbirths Series call for action to reach these goals by 2020:

• For countries with a stillbirth rate of more than 5 per 1,000 births, at least a 50 percent reduction from the current rate;
• For those nations with a current rate of under 5 per 1,000, to eliminate all preventable stillbirths and close equity gaps.