Improved data informs efforts to end preventable stillbirths
Authors: Elizabeth M McClure, Robert L Goldenberg
Journal: The Lancet Global Health (2016)

In The Lancet Global Health, Hannah Blencowe and colleagues1Blencowe H Cousens S Jassir FB et al.National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis.Lancet Glob Health. 2016; (published online Jan 18.)http://dx.doi.org/10.1016/S2214-109X(15)00275-2Google Scholar provide an important contribution to global health through a robust modelling effort to estimate the global stillbirth rates at 28 weeks or more on both a country and regional basis. Crucially, they use consistent methods and extensive data sources to determine stillbirth trends over time since 2000. With the improved modelling, the global stillbirth rate in 2015 is now estimated to be 18·4 per 1000 births, a 24% decrease from the estimated global stillbirth rate of 24·7 per 1000 births in 2000. These modelling methods are necessary to determine stillbirth trends because the regions with the highest stillbirth rates—low-income and middle-income countries (LMICs)—generally have poor registration systems. Historically, stillbirth rates have been absent altogether from registries in many regions.2AbouZahr C Cleland J Coullare F et al.for the Monitoring of Vital Events (MoVE) writing groupThe way forward.Lancet. 2007; 370: 1791-1799Summary Full Text Full Text PDF PubMed Scopus (73) Google Scholar While many high-income countries use a lower gestational age limit of 20–24 weeks to define stillbirth, WHO has recommended 28 weeks (generally considered as the lower limit of viability in LMICs) for international comparisons.3World Health OrganizationStillbirth.http://www.who.int/maternal_child_adolescent/epidemiology/stillbirth/en/Google Scholar Because half of all stillbirths in the USA and Australia occur between 20 weeks and 28 weeks,1Blencowe H Cousens S Jassir FB et al.National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis.Lancet Glob Health. 2016; (published online Jan 18.)http://dx.doi.org/10.1016/S2214-109X(15)00275-2Google Scholar the stillbirth estimates reported by Blencowe and colleagues using the 28 week cutoff are likely far lower than the rates had a 20–24 week cutoff been used. It is important not to forget the millions of stillbirths that occur worldwide at less than 28 weeks. The stillbirth rates ranged from less than two per 1000 in six western European countries to more than 40 per 1000 in Pakistan and Nigeria. Most countries with the highest stillbirth rates are in sub-Saharan Africa, whose countries have also shown the slowest declines in stillbirth rates in the past 15 years. Nearly 80% of all stillbirths worldwide occur in sub-Saharan Africa and south Asia. What contributes to the disparity in stillbirth rates between regions? Stillbirths are often divided into those that occur antepartum and those occurring in the intrapartum period, around delivery.4Goldenberg RL McClure EM Reducing intrapartum stillbirths and intrapartum-related neonatal deaths.Int J Gynaecol Obstet. 2009; 107: S1-S3Summary Full Text Full Text PDF PubMed Scopus (28) Google Scholar Today, in high-income countries, the vast majority of stillbirths occur in the antepartum period, are very preterm, and are difficult to prevent. However, in the 1930s, high-income countries had stillbirth rates similar to those seen in sub-Saharan Africa and south Asia today.5Woods R The measurement of historical trends in fetal mortality in England and Wales.Popul Stud (Camb). 2005; 59: 147-162Crossref PubMed Scopus (29) Google Scholar The decline from stillbirth rates of 30–40 per 1000 births to the present levels of two or three per 1000 births is one of the great success stories in obstetrics and public health, but is one that policy makers, health-care providers, and the public have little knowledge of. Why the stillbirth rates declined so substantially is not completely understood, but is clearly related to improved prenatal care and monitoring before labour for conditions such as maternal syphilis, pre-eclampsia (blood pressure and urinary protein), poor fetal growth, and fetal asphyxia, and improved care during labour including fetal heart rate monitoring and expedited delivery (often by caesarean section) for several conditions including pre-eclampsia or eclampsia, placental abruption, obstructed labour, and fetal distress.6Goldenberg RL Saleem S Pasha O Harrison M McClure EM Reducing stillbirths in low-income countries.Acta Obstet Gynecol Scand. 2015; (published online Nov 17)https://doi.org/10.1111/aogs.12817Crossref Scopus (23) Google Scholar Today, intrapartum stillbirths are rare in high-resource settings and when they occur are generally considered to be a consequence of poor obstetric care. By contrast, in sub-Saharan Africa and south Asia, over half of all stillbirths occur during the intrapartum period, most at term or in the late preterm period, and are free of congenital anomalies. These fetuses would not suffer the complications of preterm birth if delivered alive. Prevention of intrapartum stillbirths in LMICs should be feasible through provision of access to good quality obstetric care. Most intrapartum stillbirths are caused by asphyxia related to several maternal and fetal conditions including pre-eclampsia or eclampsia, prolonged and obstructed labour, multiple births, abnormal presentations, and cord accidents. Fetuses that are small for gestational age are especially vulnerable, probably because of poor placental function leading to asphyxia. The maternal conditions contributing to stillbirth also cause maternal and neonatal deaths. Programmes aimed to address those conditions through improvement of quality of care should have an effect on all outcomes.6Goldenberg RL Saleem S Pasha O Harrison M McClure EM Reducing stillbirths in low-income countries.Acta Obstet Gynecol Scand. 2015; (published online Nov 17)https://doi.org/10.1111/aogs.12817Crossref Scopus (23) Google Scholar Our recent study of factors related to the high stillbirth rates in Pakistan suggested that a combination of low maternal educational levels (most women cannot read or write), restricted access to prenatal and delivery care, and poor quality of care when it is available, were important contributors to the high stillbirth rates noted.7Pasha O Saleem S Ali S et al.Maternal and newborn outcomes in Pakistan compared to other low and middle income countries in the Global Network's Maternal Newborn Health Registry: an active, community-based, pregnancy surveillance mechanism.Reprod Health. 2015; 12: S15Crossref PubMed Scopus (43) Google Scholar Research such as this is needed to inform public health programmes so that stillbirth rates can be reduced. The modelling by Blencowe and colleagues1Blencowe H Cousens S Jassir FB et al.National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis.Lancet Glob Health. 2016; (published online Jan 18.)http://dx.doi.org/10.1016/S2214-109X(15)00275-2Google Scholar to determine reliable stillbirth rates by country and region is an important first step to track global progress in reducing stillbirth. However, documenting intrapartum versus antepartum stillbirth rates and accurate gestational age dating are also important to inform programmatic action. Finally, classification systems to define specific causes of stillbirth are needed. Ultimately, reliable data are crucial to inform quality improvement programmes and to track the global progress towards ending preventable stillbirths. We declare no competing interests. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysisProgress in reducing the large worldwide stillbirth burden remains slow and insufficient to meet national targets such as for ENAP. Stillbirths are increasingly being counted at a local level, but countries and the global community must further improve the quality and comparability of data, and ensure that this is more clearly linked to accountability processes including the Sustainable Development Goals. Full-Text PDF Open Access