Stillbirths: still neglected?
Authors: Zoë Mullan
Journal: The Lancet Global Health (2016)

5 years ago, The Lancet published a groundbreaking (and taboo-breaking) Series on stillbirths. Its powerful mix of advocacy and hard data attracted more media attention than perhaps any other Series, and made waves on numerous levels, from the individual to the intergovernmental. Working closely with countries and WHO, the Series authors fought to bring "out of the shadows" the unacceptable toll of intrapartum stillbirths in low-income countries, the addressable differences in stillbirth rates between countries with advanced health systems, and the deplorable absence of such devastating events from global tracking efforts such as those of the UN, the Millennium Development Goals, and the Global Burden of Disease. The Series brought home the injustice of ignoring these missing 2·6 million annual deaths, which result from the very same causes as those that kill newborn babies and pregnant women—ie, complications of childbirth, maternal infections, maternal disorders such as hypertension and diabetes, fetal growth restriction, and congenital abnormalities. Last week saw the publication of a follow-up Series that begins with a paper assessing progress and finishes with a call to end preventable stillbirths by 2030. In this month's issue of The Lancet Global Health, we publish a linked Article in which the Stillbirth Series authors update the landmark 2011 paper that produced the estimate of 2·6 million deaths. In the updated Article, Hannah Blencowe and colleagues refine their methods by including more datapoints (almost twice as many as in 2011) and applying more stringent inclusion and exclusion criteria. Modelling was done for missing datapoints, of which there were sadly still many—only 32% of countries in southeast Asia had national data available. The authors find that the global estimate for 2015 is also 2·6 million, but the uncertainty range is narrower (2·4–3·0 million vs 2·14–3·82 million for the previous estimate). They compare this with an estimate of 3·25 million for 2000, corresponding to a 19·4% decrease (uncertainty range −1·8 to 36·9%) since that date. The slowest rate of decline was in sub-Saharan Africa and the fastest was in east Asia. The dominant nation in east Asia, China, has seen dramatic reductions in infant and child mortality, particularly in the past 15 years. Yet at the time of the previous Series estimates in 2011, no national data on stillbirths were available. To make up for this shortcoming, Jun Zhu and colleagues, who report their findings in a further Article published in this month's issue, collected data on birth outcomes from 441 hospitals across China by means of the National Maternal Near Miss Surveillance System. This ambitious study found that, of the nearly 4 million births in the studied hospitals between 2012 and 2014, 37 855 were stillbirths at 28 weeks' gestation or later, giving a stillbirth rate of 8·8 per 1000 births. Compared with Blencowe and colleagues' global estimate of 18·4 per 1000 births for 2015, China comes out relatively well overall. The rate varied vastly by age and socioeconomic status, however, with strikingly high rates for women who were younger than 15 years, had not used antenatal care, were unmarried, or had no education. Globally, monitoring and prioritisation efforts have seen some improvements since the previous Stillbirths Series. The adoption of the Every Newborn Action Plan at the WHO General Assembly in 2014 was a milestone in this regard. It calls for the stillbirth rate to be a core indicator of progress and sets a global target of 12 or fewer stillbirths per 1000 births by 2030. Furthermore, stillbirths are firmly imbedded in the UN's newly updated Global Strategy for Women, Children's and Adolescents' Health (2016–30), which, like The Lancet's Series, includes the aim of ending preventable stillbirths by 2030. Nationally, however, progress has been uneven. For example, despite the Chinese Government's admirable dedication to the reduction of maternal and neonatal mortality, its commitment to the issue of stillbirths is wanting. As Zhu and colleagues point out, "The annual number of stillbirths equals the annual number of neonatal deaths in China, yet stillbirths do not feature in the government's 5 year plan for development of health or National Programme of Action for women and children. Most information systems do not include stillbirths, and data, where available, are not used". The Chinese Government should take the publication of these data as a prompt to (1) incorporate standardised stillbirth measurement and monitoring into national strategic plans, and (2) "invest strategically in antenatal care, particularly for the most disadvantaged women, including the very young, unmarried, and illiterate". For The Lancet's Series on ending preventable stillbirths see http://www.thelancet.com/series/ending-preventable-stillbirths For The Lancet's Series on ending preventable stillbirths see http://www.thelancet.com/series/ending-preventable-stillbirths 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 AccessSociodemographic and obstetric characteristics of stillbirths in China: a census of nearly 4 million health facility births between 2012 and 2014Our analysis of nearly 4 million births in 441 health facilities in China suggests a stillbirth rate of 8·8 per 1000 births between 2012 and 2014. Stillbirths do not feature in the Chinese Government's 5 year plans and most information systems do not include stillbirths. The Government need to start paying attention to stillbirths and invest strategically in antenatal care, particularly for the most disadvantaged women, including the very young, unmarried, and illiterate, and those at high parity. Full-Text PDF Open Access