Stillbirths: ending an epidemic of grief

Not all global health issues are truly global, but the neglected epidemic of stillbirths is one such urgent concern. The Lancet’s fi rst Series on stillbirths was published in 2011. Thanks to tenacious eff orts by the authors of that Series, led by Joy Lawn, together with the impetus of a wider maternal and child health community, stillbirths have been recognised as an essential part of the post-2015 sustainable development agenda, expressed through a new Global Strategy for Women’s, Children’s and Adolescents’ Health which was launched at the UN General Assembly in 2015. But recognising is not the same as doing. We now present a second Series on stillbirths, which is predicated on the idea of ending preventable stillbirth deaths by 2030. As this Series amply proves, such an ambitious goal is possible. The fi ve Series papers off er a roadmap for eliminating one of the most neglected tragedies in global health today. Perhaps the greatest obstacle to addressing stillbirths is stigma. The utter despair and hopelessness felt by families who suff er a stillbirth is often turned inwards to fuel feelings of shame and failure. The idea of demanding action would be anathema for many women and men who have experienced the loss of a child in this appalling way. This Series dispels any notion that such self-recrimination is justifi ed. Most stillbirths have preventable causes—maternal infections, chronic diseases, undernutrition, obesity, to name only a few. The solutions to ending preventable stillbirths are therefore practicable, feasible, and cost eff ective. They form a core part of the continuum of care—from prenatal care and antenatal care, through skilled birth attendance, to newborn care. The number of stillbirths remains alarmingly high: 2·6 million stillbirths annually, with little reduction this past decade. But the truly horrifi c fi gure is 1·3 million intrapartum stillbirths. The idea of a child being alive at the beginning of labour and dying for entirely preventable reasons during the next few hours should be a health scandal of international proportions. Yet it is not. Our Series aims to make it so. When a stillbirth does occur, the health system can fail parents further by the absence of respectful, empathetic services, including bereavement care. Yet provision of such care is not only humane and necessary, it can also mitigate a range of negative emotional and psychological symptoms that mothers and fathers experience after the death of their baby, some of which can persist long after their loss. Ten nations account for two-thirds of stillbirths: India, Nigeria, Pakistan, China, Ethiopia, Democratic Republic of the Congo, Bangladesh, Indonesia, Tanzania, and Niger. Although 98% of stillbirths take place in low-income and middle-income countries, stillbirth rates also remain unacceptably high in high-income settings. Why? Partly because stillbirths are strongly linked to adverse social and economic determinants of health. The health system alone cannot address entirely the predicament of stillbirths. Only by tackling the causes of the causes of stillbirths will rates be defl ected downwards in high-income settings. There is one action we believe off ers promising prospects for accelerating progress to end stillbirths—stronger independent accountability both within countries and globally. By accountability, we mean better monitoring (with investment in high-quality data collection), stronger review (including, especially, civil society organisations), and more robust action (high-level political leadership, and not merely from a Ministry of Health). The UN’s new Independent Accountability Panel has an important part to play in this process. But the really urgent need is for stronger independent accountability in countries. And here is where a virtuous alliance might lie between health professionals, clinical and public health scientists, and civil society, including bereaved parents. We believe this Series off ers the spark to ignite a new alliance of common interests to end preventable stillbirths by 2030.