A stillbirth can lead to long-term depression.
The findings appear in a series of five papers entitled, "Ending Preventable Stillbirth," involving 216 experts from more than 100 organizations in 43 countries.
"Stillbirth" is when a child dies during the final trimester of pregnancy, or after 28 weeks gestation. Half of all stillbirths occur during the birthing process.
The Every Newborn Action Plan stillbirth target is 12 or fewer stillbirths per 1,000 total births by 2030.
While 98% of stillbirths occur in low- and middle-income countries (LMICs), they also remain a problem for high-income countries (HICs).
Co-lead author Prof. Joy Lawn, from the London School of Hygiene & Tropical Medicine in the UK, and colleagues found that from 2000-2015, the global average stillbirth rate fell from 24.7 per 1,000 births to 18.4, equivalent to an annual rate of reduction of 2%.
Even where countries have met the target, wide gaps persist between rich and poor. A number of African countries need to at least double their progress.
The greatest reduction has been in the Netherlands, down 6.8% annually since 2000, with improvements in antenatal care and care at birth, a wide-scale perinatal audit and a focus on women's health before and during pregnancy.
Among LMICs, the rate has fallen by 3.6% in Cambodia, 3.4% in Bangladesh and 2.9% in Rwanda. Rwanda has doubled the number of births in health facilities and improved the quality of health facilities and antenatal care.
Causes of stillbirth
Contrary to popular belief, data suggest that only 7.4% of cases result from congenital abnormalities. Many disorders associated with stillbirths are modifiable.
- In the US, there are 3 stillbirths per 1,000 births
- Iceland's rate is the lowest, at 1.3 per 1,000 births
- Pakistan has the highest rate, at 43.1 per 1,000 births.
These include maternal infections such as malaria (8%) and syphilis (7.7%). About 10% of cases relate to non-communicable diseases, nutrition and lifestyle. In 6.7% of cases, the mother was over 35 years of age. Pre-eclampsia and eclampsia contribute to 4.7% of stillbirths, while 14% relate to prolonged pregnancies.
In Sub-Saharan African countries, especially those facing conflicts and emergencies, stillbirth rates are high and progress is slow. The rate in Nigeria is 42.9 per 1,000 live births, with an average reduction of 1.3 stillbirths per 1,000 per year since 2000. At this rate, it will be another 160 years until the average Sub-Saharan African woman has the same chance of a live birth as a woman living now in an HIC.
Even in HICs, the risk of a stillbirth for a socioeconomically disadvantaged woman is double that of her wealthier counterparts. Findings link substandard care with 20-30% of all stillbirths in HICs.
Stillbirth rates for women of South Asian and African origin in Europe or Australia are 2-3 times higher than for white women. Education, alleviation of poverty and improved access to health care, especially timely, culturally appropriate antenatal care, are recommended.
The researchers call for a systematic classification and research into the causes of stillbirth in HICs, as well as interventions to help women to begin pregnancy with a normal bodyweight.
Grieving for the loss after stillbirth
Stigma was particularly evident in LMICs. In cultures where talking about death is taboo, and where the dead baby is not yet deemed to be a person, mothers tend to suppress grief in public and deal with the emotions privately and alone.
These parents are also less likely to be offered contact with their baby, the opportunity to see and hold their baby and to name their baby after a stillbirth.
In HICs, around 50% of parents felt pressure not to talk about their stillborn baby "because it makes people feel uncomfortable."
Between 60-70% of grieving mothers reported clinically significant depressive symptoms a year after their baby's death, and 50% of them experienced these symptoms for at least 4 years after the loss.
Stillbirth entails substantial direct, indirect, psychological and social costs to women, their families, society and governments.
Researchers call for greater empathy with those affected. Health workers need a better understanding of what parents and families need and when they need it. Communities need to acknowledge grief and loss and not to stigmatize those who have had stillbirths. Employers should provide effective leave arrangements, and governments should provide tangible support, such as funeral costs and paid leave from work commitments.
Important milestones that have been achieved include work in the areas of family planning, antenatal care, care during labor and birth, supportive care, reduction of stigma and improved monitoring and research.
However, there is a need for "intentional incorporation of stillbirths into global, regional, and national policy frameworks for women's and children's health."
Researchers point out:
"Although some progress has been made, this reduction has been slower than for maternal (3%), neonatal (3.1%), and postneonatal mortality of children younger than 5 years (4.5%) over the same period."
In a linked comment, The Lancet Editor-in-chief Richard Horton and Senior Editor Udani Samarasekera call the number of stillbirths "alarmingly high," particularly the 1.3 million children who die during labor "for entirely preventable reasons." This, they say, "should be a health scandal of international proportions."
Medical News Today recently reported that using oral fungicides to treat candida during pregnancy can lead to stillbirth.