Each day more than 7,300 babies are stillborn – a death just when a parent expects to welcome a new life. Each one is an individual story of a family devastated by the loss of their child. Yet these millions of stillbirths occur uncounted each year and are not reflected in global policy. Until now, United Nations (UN) data have not included stillbirths. Global policy targets such as the Millennium Development Goals (MDGs), omit stillbirths. As Gary Darmstadt and Becky Ferguson note in their post, the extensive research and analysis presented in the Lancet Stillbirth Series provides the most comprehensive assessment to date of global numbers and causes of stillbirths, as well as beliefs around the world, and solutions to prevent stillbirths. The Bill & Melinda Gates Foundation has helped make possible this pioneering effort to shine a light on the burden of stillbirths for our poorest families, around the world. Partners from Save the Children, to Aga Khan University, Pakistan, to the World Health Organization (WHO) have worked collectively for the past five years, to remind the world that stillbirths will no longer be invisible but given the attention this issue deserves.
Variation around the world for stillbirth rates in 2008 New estimates for third trimester stillbirth rates in 193 countries undertaken through a collaborative effort including the World Health Organization and also providing time trends 1995-2009
Where? At least 2.6 million third-trimester stillbirths occur every year; 98 percent in low- and middle-income countries. More than half of all stillbirths affect rural families in Sub-Saharan Africa and South Asia where women often do not have access to skilled health providers during childbirth. Ten countries account for two-thirds of stillbirths, two-thirds of neonatal deaths and over 60 percent of maternal deaths (see map).
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When? Worldwide, 1.2 million stillbirths happen after the mother has gone into labour. These are mainly full-term babies who would be saved with better care at birth. This is called intrapartum stillbirth and the risk for an African woman is 24 times higher than for a woman in the US or the UK. Stillbirths that happen before labour are called antepartum and account for more than half of stillbirths around the world. Reducing the number of babies who die before labour requires improving care during pregnancy, especially targeting maternal infections, hypertension, and poor fetal growth.
Why? Every parent of a stillborn wants to understand why, and clinicians and policymakers should be able to answer. However, collecting comparable estimates for the causes of stillbirths and linked maternal conditions in low-and middle-income countries is impeded by more than 35 different classification systems, mainly designed for use in rich countries. Despite limitations in the available data, the most common causes of stillbirth and associated maternal conditions are clear.
The “big five” causes of stillbirths are similar to those that also kill mothers and babies:
- Childbirth complications;
- Maternal infections in pregnancy;
- Maternal conditions, especially hypertension and diabetes;
- Fetal growth restriction; and
- Congenital abnormalities.
Counting better? Most stillbirths occur in countries without adequate birth and death certificates. Data on stillbirths and other pregnancy outcomes could be improved immediately by counting stillbirths better in existing systems, especially household surveys, and vital registration. Urgent attention is required to better count and to develop a simplified standard programmatic classification for stillbirths. Counting stillbirths will show added value for maternal and newborn care programs, especially at the time of birth.
Change by 2020: If we are to reduce the number of stillbirths, globally, we must increase awareness of the issue and ensure stillbirth receives the attention it deserves. The average annual rate of reduction has been slower for stillbirths (estimated 1.1 percent between 1995 and 2008) than for maternal and child mortality reductions (2.5 and 2.3 percent per year). We are making progress but without an acceleration of this progress, by 2020 more than 90 percent of all stillbirths will be in South Asia and Sub-Saharan Africa. To ensure stillbirths are given adequate attention, the issue should be included in post-Millennium Development Goal (MDG) targets. Every country should have national estimates of stillbirth rates and causes. Global agencies should collect stillbirth data, facilitate yearly estimates, and improve national death certificates and counting systems.
We call for the international community, individual countries, professional organisations, and families to take a stand for stillbirths. Everyone has a role to play and together stillbirths can and must be counted and reduced.