Stillbirths Remain Major Public Health Concern

By Lilian Museka

Some 2.6 million third trimester stillbirths worldwide occur every year, according to the first comprehensive set of stillbirth estimates, published today within a special series in the medical journal The Lancet.

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

Ninety-eight per cent 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), foetal 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 comprised of six scientific papers, two research articles, and eight linked comments.

Joy Lawn, 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,  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.

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

Before-labour 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.

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,  Director, Family Health Division, Global Health Program, Bill & Melinda Gates Foundation.

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.

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.

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.