98% of the 2.6 million stillbirths that occur globally each year are in low-income and middle-income countries - even so, among wealthy nations the toll is still high, estimated to be at about 1 in every 320 births, according to an article among a Series published this week in Lancet. The Series covers stillbirth rates worldwide, and puts forwards some proposed key actions that should be in place by 2020 to reduce this devastating event.
The 2.6 million stillbirths refers specifically to the WHO (World Health Organization) definition - ones that occur after 28 weeks of pregnancy, or the last trimester. A stillbirth is when the fetus has died in the uterus and the mother delivers the remains, including a baby that is not alive.
In the majority of rich nations, a still birth occurs after the 22nd week of pregnancy. If this definition were used there would be 45% more stillbirths in the annual global count. In rich countries, 1 in 200 births are stillborn from the 22nd week of pregnancy onwards, compared to 1 in 320 if they occur after 28 weeks.
Joy Lawn and team discuss the implications of the nationally reviewed stillbirth estimates WHO undertook. Rates worldwide vary considerably, from 1 in 500 in Finland to over 1 in 25 births in Nigeria or Pakistan. Over three-quarters of all stillbirths occurred in sub-Saharan Africa and south Asia, the authors report. Only 2% of stillbirths occur in developed nations. The majority of rich nations have fewer than 5 still births per 1,000 births. If developed nation stillbirth rates occurred globally, millions more babies would be born alive.
About 1.4 million stillbirths occur antepartum (before birth) while 1.2 million occur intrapartum (during birth). The majority of stillbirths that occur during birth are the result of childbirth complications, also known as obstetric emergencies, which have been mostly eliminated in wealthy nations.
Most stillbirths that occur antepartum are generally linked to maternal infections and fetal growth problems. Syphilis, for example, is a major preventable cause of stillbirth, which is fairly common in some nations. The biggest risk factors in rich countries are maternal age, smoking, and/or obesity.
In 1995 there were 3.03 million still births worldwide, compared to 2.64 million in 2009 - an overall drop from 22 per 1,000 to 19 per 1,000. While child-under-5 mortality fell 2.5% annually from 1995 to 2009, the stillbirth rate only dropped by 1.1% each year during the same period. Maternal mortality dropped by an average 2.5% per year.
Colombia, China and Mexico have had the largest falls in stillbirth rates from 1995 to 2009.
Black women in the UK and USA, and Indigenous females in Canada and Australia have double the risk of stillbirth compared to Caucasian women.
It is a myth to believe that stillbirth is an unfortunate, inevitable loss that cannot be prevented. Only 1 in every 20 stillbirths are linked to any congenital abnormality. Many do not realize or acknowledge that the risk of stillbirth is 3 times greater at 40 weeks of pregnancy than earlier on.
Dr Frederik Frøen, Norwegian Institute of Public Health, and team accuse those who could have created awareness to prevent stillbirths of not doing so, such as socio-political leaders and others. The Millennium Development Goals did not include stillbirths.
Women who give birth to a stillborn child are at risk of developing depression, anxiety, PTSD (post-traumatic stress disorder), as well as facing the stigma of being a failed mother.
Even though stillbirths during the third trimester represent more deaths than malaria and AIDS deaths combined, the subject receives scant attention on the world stage.
In poorer nations there are virtually no bereavement rituals for a stillbirth. In rich nations acknowledgment of mother's and father's grief is a recent phenomenon. The authors quote a survey of health-care professionals and parent that revealed that in 135 nations most babies that are stillborn are disposed of with no rituals or recognition - there is no naming of the baby, funeral rites, or allowing the mother to hold or dress the baby.
Some interventions could make a huge difference to stillbirth rates, the authors explain. Prof Zulfiqar Bhutta and team quote 10 interventions backed with 99% coverage could reduce current stillbirth rates by at least 50%. Universal coverage would also impact positively on neonatal and maternal death, at not much cost.
2020 VisionProf Robert L Goldenberg and team propose a target for all nations with a stillbirth rate under 5 per 1,000 to eliminate every preventable births, while those with a rate of more than 5 per 1,000 to bring down the stillbirth burden by half.
The 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."
Stillbirth reduction drives should be included in all maternal and neonatal programs, the authors add. Data should be included in all relevant reports regarding stillbirth rates and cause of death. The gathered data should be placed in a new universal classification system, and then an effective business model should be created to bring the rates down.
In a communiqué, the Lancet writes:
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."
Launched in London, New York, Hobart, Geneva, New Delhi, Florence, and Cape Town on April 14, 2011
"An Executive Summary for The Lancet's Series" (PDF)
Written by Christian Nordqvist