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More progress needed to prevent stillbirths globally

Poor care accounts for 20-30% of cases in rich nations

Jo Carlowe

Tuesday, 19 January 2016

Falls in stillbirth rates are failing to keep pace with a drop in childhood and maternal mortality rates, new research shows.

In The Lancet’s ‘Ending preventable stillbirths Series’, it’s revealed that approximately 2.6 million babies were stillborn in 2015, or around 7,200 every day globally. Half of these occur intrapartum. 

While 98% of stillbirths occur in low-income and middle-income countries, they also remain a problem for high-income countries. 

Series co-lead Professor Joy Lawn from the London School of Hygiene & Tropical Medicine, and colleagues, found that from 2000 to 2015, the global average stillbirth rate fell from 24·7 per 1,000 total births to 18·4 - equivalent to an annual rate of reduction (ARR) of 2% for stillbirths. They say: “Thus, although some progress has been made, this reduction has been slower than for maternal (ARR 3%), neonatal (3·1%), and postneonatal mortality of children younger than 5 years (4·5%) over the same period.”

The authors also highlight that, for every country to reach the Every Newborn Action Plan stillbirth target of 12 or fewer stillbirths per 1,000 total births by 2030, this global ARR will need to more than double to 4.2%. A total of 94 mainly high-income countries and upper middle-income countries have already met this target, yet most of these still have wide equity gaps between the poorest and richest families. Notably 56 countries, mainly in Africa, need to at least double their progress to meet the target.

The Series also provides new findings on the preventability of stillbirths. Data from 18 countries suggests that congenital abnormalities account for a median of only 7·4% of stillbirths, dispelling the myth that all stillbirths are inevitable and are due to congenital conditions. Many disorders associated with stillbirths are modifiable and often coexist, such as maternal infections (malaria and syphilis account for 8.0% and 7·7% of stillbirths respectively), non-communicable diseases, nutrition and lifestyle factors (each about 10%), and maternal age older than 35 years (6·7%). Pre-eclampsia and eclampsia together contribute to 4·7% of stillbirths, while prolonged pregnancies contribute to 14% of stillbirths.

The authors highlight a number of countries that have made impressive progress. Among high income countries (HIC), the Netherlands had the highest annual rate of reduction from 2000 to 2015 (6·8%), attributed to improvements in antenatal care and care at birth, a wide-scale perinatal audit, coupled with a focus on women’s health before and during pregnancy.

Among low and middle-income countries (LMIC), Cambodia (ARR 3·6%), Bangladesh (3·4%) and Rwanda (2·9%) have made faster progress in stillbirth prevention than their neighbours. Rwanda for example has doubled the number of births in health facilities and improved the quality of this care as well as that of antenatal care.

Professor Joy Lawn and colleagues say: “Sub-Saharan Africa has the highest stillbirth rates and the slowest rates of progress worldwide, especially in countries with conflicts and emergencies. Thus at the present rates of progress, over 160 years will pass before the average pregnant woman in sub-Saharan Africa has the same chance of her baby being born alive as does a woman nowadays in a high-income country.”

Stillbirths remain a problem in high income countries (HIC) where variations in stillbirth rates across countries and large equity gaps persist. Estimates show an average stillbirth rate (after 28 weeks gestation) in 49 HICs of 3·5 per 1000 total births. Country-specific rates varied widely from 1·3 (Iceland) to 8·8 (Ukraine).

Dr Vicki Flenady, Mater Research Institute, University of Queensland, Australia and colleagues conclude that if all high income countries (HICs) achieved stillbirth rates equal to the best performing countries (stillbirth rate 2 or less per 1,000 births), an estimated 19,400 late gestation (28 weeks or more) stillbirths could have been avoided in 2015. National mortality audit data suggest substandard care contributes to 20–30% of all stillbirths in HIC.

Flenady and colleagues call for national perinatal mortality audit programmes to be implemented in all high-income countries, including a systematic approach to classifying the causes of stillbirth and research focusing on stillbirth prediction, understanding placental pathways to stillbirth and causal pathways to unexplained stillbirth. They add that interventions to increase the number of women beginning pregnancy with a normal bodyweight are crucially important to improve pregnancy outcomes and longer-term health.

They conclude: “Stillbirths are a major public health issue in HICs and reductions in rates have not matched those for neonatal mortality. Variation and socioeconomic disparities in stillbirth rates, suboptimum uptake of interventions, low proportions of stillbirths attributed to congenital abnormality and high proportions classified as unexplained, and the contribution of substandard care factors suggest stillbirths are not inevitable, and that further reduction in HICs is possible.”

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