Stillbirths

by

Vicki Flenady, Chrissie Astell, Laura Singline, Aleena Wojcieszek, Jessica Sexton, David Ellwood, Philippa Middleton, Adrienne Gordon, Caroline Homer, Joshua Vogel, Alyce Wilson, Frances M. Boyle, Siobhan Loughnan, Christine Andrews

• LAST REVIEWED: 27 October 2021
• LAST MODIFIED: 27 October 2021
• DOI: 10.1093/obo/9780199756797-0210

Introduction

Stillbirth is a major public health problem that often has long-lasting psychological, social, and financial burden on parents and families. Globally, an estimated 1.9 million women every year will experience the tragedy of a late-gestation stillbirth (twenty-eight weeks or more). Due to paucity of data, stillbirths below twenty-eight weeks’ gestation are not included in global estimates, and therefore the current global estimate vastly underestimates the incidence of stillbirth. Low- and middle-income countries bear the brunt of the global burden of stillbirth, where the majority could be prevented with adequate pregnancy and emergency obstetric care. Although high-income countries’ rates are comparatively low, many stillbirths are preventable in these settings through improved maternity care. Further, stillbirth rates for disadvantaged populations remain unacceptably high. Despite the scale of the problem and potential for prevention, stillbirth has been neglected in the global health agenda. The lack of visibility and acknowledgment of stillbirth as a profound loss for families and a fatalism around stillbirth have been major contributors to the inertia in stillbirth prevention. However, initiatives since the early 2010s are slowly bringing about change. The 2011 and 2016 Lancet Stillbirth series shone a light on stillbirth, with a call for action, and in 2014 the Every Newborn Action Plan (ENAP) included country stillbirth rate targets. A major step forward has been the inclusion of stillbirths in the 2020 UN Inter-agency Group for Child Mortality Estimation (UN IGME) report. Improving data on stillbirths through accurate counting, perinatal mortality audit, and standardized classification is vital to develop and monitor effective prevention strategies. While some improvements in global stillbirth rates since the turn of the 21st century are evident, much more needs to be done. The COVID-19 pandemic (2020–) has disrupted maternity care, which may be increasing stillbirth rates and compounding grief for families whose babies are stillborn through social isolation. Efforts to ensure optimal care throughout the COVID-19 pandemic are critically important, particularly for disadvantaged populations. Despite best efforts, not all stillbirths will be prevented. Providing respectful supportive care for all parents after stillbirth and in subsequent pregnancies is critical to improve longer-term outcomes associated with this tragedy. Written on behalf of the International Stillbirth Alliance (ISA). We acknowledge and thank the ISA for their ongoing support and commitment to ending preventable stillbirths.

Epidemiology and Data to Drive Change

The UN Inter-agency Group for Child Mortality Estimation 2020 estimates that 1.9 million late-gestation stillbirths (twenty-eight weeks or later) occur every year. Around 98 percent of stillbirths occur in low- and middle-income countries, particularly in sub-Saharan Africa and South Asia. The 2011 Lancet series marked an initial step in a global effort to reduce the burden of stillbirth. The resulting Every Newborn Action Plan (ENAP) (World Health Organization 2014) focuses on strategies to reduce neonatal deaths and stillbirths to a rate of twelve or fewer per one thousand births in every country by 2030. In the 2016 Lancet series, Blencowe, et al. 2016 and Lawn, et al. 2016 present key contextual evidence on the burden of stillbirth in achieving ENAP and Millennium Development Goal targets. The UN Inter-agency Group for Child Mortality Estimation 2020 shows that while progress is being made, fifty-six countries are not on track to meet ENAP targets, and an additional twenty million stillbirths will take place before 2030 if current trends continue. Accurate registration of stillbirths and reliable data on causes and contributory factors are critical to prevention but lacking in many regions. Blencowe, et al. 2016 shows that most stillbirths in low- and middle-income countries are captured only through surveys and research studies. In respective systematic reviews, Leisher, et al. 2016 and Flenady, et al. 2017 describe a plethora of disparate and largely suboptimal classification systems for causes of stillbirths, resulting in a high proportion of unexplained stillbirths. High-quality perinatal mortality audit is essential in improving the quality of data to drive change and to help parents understand why their baby died. Flenady, et al. 2011 highlights the lack of such programs across high-income countries. To improve the quality of data for stillbirth and neonatal deaths, the World Health Organization (WHO) developed the ICD-perinatal mortality classification system and a guide to perinatal mortality audit (World Health Organization 2016). Flenady, et al. 2011 identifies that the largest contributor to stillbirth across high-income countries is undetected fetal-growth restriction (FGR), with small-for-gestational age (proxy for FGR) accounting for 26 percent of stillbirths. The authors also found three major and potentially modifiable risk factors for stillbirth in high-income countries: overweight and obesity (8–18 percent), smoking (4–7 percent), and maternal age over thirty-five years (7–11 percent). Lawn, et al. 2016 reports major risk factors globally as maternal age older than thirty-five years (6.7 percent), noncommunicable diseases, lifestyle factors (each about 10 percent), and maternal infections in low- and middle-income countries (malaria, 8 percent; syphilis, 7.7 percent). Using predictive models for stillbirth, Malacova, et al. 2020 shows that 45 percent of stillbirths could be potentially identified antenatally on the basis of a combination of risk factors, including pregnancy complications, congenital anomalies, maternal characteristics, and medical history. Cronin, et al. 2019 finds supine going-to-sleep position is associated with 5.8 percent of late-gestation stillbirths.

• Blencowe, H., S. Cousens, F. B. Jassir, et al. 2016. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: A systematic analysis. The Lancet Global Health 4.2: e98–e108.

  DOI: 10.1016/S2214-109X(15)00275-2

  A systematic analysis of global stillbirth rates in 2015 in 157 countries, showing an estimated stillbirth rate of 18.4/1,000, which is a reduction from 24.7/1,000 in 2000. About 98 percent of all stillbirths occur in low- and middle-income countries, with 77 percent in South Asia and sub-Saharan Africa; sub-Saharan Africa had the slowest rate reduction. The authors call for better-quality data on stillbirths and for linking stillbirth rates with accountability processes including the Sustainable Development Goals.

• Cronin, R. S., M. Li, E. A. Mitchell, et al. 2019. An individual participant data meta-analysis of maternal going-to-sleep position, interactions with fetal vulnerability, and the risk of late stillbirth. EClinicalMedicine 10 (April): 49–57.

  DOI: 10.1016/j.eclinm.2019.03.014

  A meta-analysis of individual participant data, using all available worldwide data, demonstrated an adjusted odds ratio of 2.63 (95 percent CI 1.72–4.04) for late stillbirth in women who reported a supine going-to-sleep position. Going to sleep on the left or right side appeared equally safe.

• Flenady, V., L. Koopmans, P. Middleton, et al. 2011. Major risk factors for stillbirth in high-income countries: A systematic review and meta-analysis. The Lancet 377.9774: 1331–1340.

  DOI: 10.1016/S0140-6736(10)62233-7

  A systematic review and meta-analysis of population-based studies that identifies the main risk factors for stillbirth in high-income countries. Findings show that potentially modifiable factors of overweight and obesity, maternal age, and smoking are major contributors to stillbirth in high-income countries. Small-for-gestational age is shown to be the biggest single contributor.

• Flenady, V., A. M. Wojcieszek, D. Ellwood, et al. 2017. Classification of causes and associated conditions for stillbirths and neonatal deaths. Seminars in Fetal & Neonatal Medicine 22.3: 176–185.

  DOI: 10.1016/j.siny.2017.02.009

  This paper reviews the classification systems for causes of stillbirth and neonatal deaths. It also discusses the next steps in developing more-detailed systems for identifying causes as well as risk factors for stillbirth globally.

• Lawn, J. E., H. Blencowe, P. Waiswa, et al. 2016. Stillbirths: Rates, risk factors, and acceleration towards 2030. The Lancet 387.10018: 587–603.

  DOI: 10.1016/S0140-6736(15)00837-5

  The second paper in The Lancet’s 2016 Ending Preventable Stillbirths series notes that an estimated 2.6 million third-trimester stillbirths were reported in 2015. Subsequently, it focuses on the progress of stillbirth prevention since the release of the ENAP in 2014 and The Lancet’s 2011 Stillbirth series.

• Leisher, S. H., Z. Teoh, H. Reinebrant, et al. 2016. Seeking order amidst chaos: A systematic review of classification systems for causes of stillbirth and neonatal death, 2009–2014. BMC Pregnancy Childbirth 16.1: 295.

  DOI: 10.1186/s12884-016-1071-0

  This systematic review provides a summary of the global classification systems used for stillbirths and neonatal deaths between 2009 and 2014. Eighty-one systems with widely varying characteristics were identified, which impeded global efforts to better understand causes of death, particularly in countries with the highest burden. The results of this review helped inform the development of the more efficient International Classification of Diseases for Perinatal Mortality (ICD-PM), led by WHO.

• Malacova, E., S. Tippaya, H. Bailey, et al. 2020. Stillbirth risk prediction using machine learning for a large cohort of births from Western Australia, 1980–2015. Scientific Reports 10.1: 5354.

  DOI: 10.1038/s41598-020-62210-9

  This large population-based cohort study based in Western Australia aimed to quantify and validate the accuracy of risk factors such as maternal characteristics, chronic medical conditions (current and previous pregnancy), obstetric complications, and family history for predicting stillbirth.

• UN Inter-agency Group for Child Mortality Estimation. 2020. A neglected tragedy: The global burden of stillbirths. New York: United Nations Children’s Fund.

  The first joint stillbirth estimates by the UN Inter-agency Group for Child Mortality Estimation presents the number of babies that are stillborn every year. The report also notes that there is a high risk that the COVID-19 pandemic may reverse decades-long progress on reducing child mortality, and may affect the number of stillbirths. This inaugural report is an essential part of global child survival initiatives.

• World Health Organization. 2014. Every newborn: An action plan to end preventable deaths. Geneva, Switzerland: World Health Organization.

  ENAP is a call to action for the global community to work together to end preventable stillbirths and newborn deaths by 2030. Five key strategic objectives and six guiding principles are discussed to help all countries achieve the goal of twelve or fewer stillbirths and newborn deaths per thousand births.

• World Health Organization. 2016. Making every baby count: Audit and review of stillbirths and neonatal deaths. Geneva, Switzerland: World Health Organization.

  Following the ENAP of 2014, this report suggests building on systems already in place to end preventable stillbirths. It draws on two of the five strategic objectives outlined in the ENAP to provide support for identifying risk factors, analyzing data, and improving the quality of care.