The Series focuses on low-income and middle-income countries, where 98% of all stillbirths occur. Paper 2 (Dr Joy Lawn and colleagues) reports the set of national stillbirth estimates undertaken with the World Health Organization, and the first time comparisons (1995-2009). This new data shows that just 10 countries represent two-thirds of all stillbirths. In order from highest to lowest, these are India, Pakistan, Nigeria, China, Bangladesh, Democratic Republic of the Congo, Ethiopia, Indonesia, Afghanistan and Tanzania. The top five alone represent half of all stillbirths worldwide.
Around two-thirds of stillbirths occur in rural families. In fact, 55% of all the world's stillbirths occur in families in rural South Asia and sub-Saharan Africa, where skilled birth attendance is at least 50% lower than in urban areas and caesarean section mostly unavailable. There have been notable successes in stillbirth reduction in many developing countries. Columbia, China, Mexico and Argentina have all reduced their stillbirth rate by 40% to 50%. But many countries, especially in sub-Saharan Africa, have seen only tiny reductions or stagnation in their stillbirth rates, even in countries where maternal and child mortality are now reducing.
There are 42 high-income countries with stillbirth rates of 5 per 1000 total births or less. 77 countries have rates of 5 to 15; 28 countries have rates of 15 to 25; and 37 countries have rates above 25 per 1000. Roughly one in every two stillbirths in developing countries occurs during birth (intrapartum). Worldwide, this means that 1.2 million babies die during labour and most of these are term babies who should survive if born alive, whose deaths are often associated with lack of obstetric care or suboptimal care.
Data collection is a challenge in low-income and middle-income countries, where 60 million births a year happen at home and few babies have birth and death certificates. The authors of paper 2 suggest that existing national household surveys could do a much better job of counting stillbirths. Consensus is needed on a core list of programmatic causes of stillbirth, as the multiple (>35), complex systems in current use mean that most of the world's stillbirths cannot be classified in a comparable way. If causes of stillbirths are not determined, then solutions are less likely and families also go without an explanation for the reason their baby died.
In the third paper (Professor Zulfiqar Bhutta and colleagues) identify the 10 interventions that would have highest impact on reducing stillbirth rates and are thus recommended for implementation: basic emergency obstetric care, comprehensive emergency obstetric care, skilled care at birth, detection and management of fetal growth restriction, detection and management of hypertensive disease of pregnancy, elective induction in post-term pregnancies, insecticide-treated bednets and intermittent prophylaxis to prevent malaria and detection, detection and treatment of syphilis, folic acid supplementation, and management of diabetes of pregnancy.
The authors estimate that universal (99%) coverage with these 10 interventions across the 68 priority countries of the Countdown to 2015 initiative to track progress on the MDGs for maternal and child health would reduce stillbirth rates by almost half (45%), at a cost of US$ 9.6 billion or $ 2.32 per person on top of existing spending. Some 1.1 million stillbirths could be averted using these interventions, distributed as follows:
INTERVENTION / STILLBIRTHS PREVENTED
- Comprehensive emergency obstetric care / 696 000
- Syphilis detection and treatment / 136 000
- Detection and management of fetal growth restriction / 107 000
- Detection and management of hypertension during pregnancy / 57 000
- Identification and induction for mothers with >41 weeks' gestation / 52 000
- Malaria prevention, including bednets and drugs / 35 000
- Folic acid fortification before conception / 27 000
- Detection and management of diabetes in pregnancy / 24 000
Though it was not included in the modelling, the authors add that strengthening family planning services would also save lives by reducing the numbers of unintended pregnancies, and thereby reduce stillbirths, as well as maternal and neonatal deaths.
The authors say their work shows stillbirth rates can be brought down by a combination of these primary care (outreach) and facility-based interventions.
"Childbirth care, especially emergency obstetric care including caesarean section, reduces the highest number of stillbirths, and should be the first priority, especially because of the additional benefits to women and newborn children. Antenatal care is low cost and effective against stillbirths related to infection and undernutrition, and can be provided through outreach workers and services," say the authors. But they add that "The high cost of interventions to address hypertension, diabetes, post-term pregnancy, and fetal growth restriction could impede implementation, but because of the associated benefits, implementation should be considered, especially in middle-income countries."
There are many opportunities for intervention in developing countries, such as general mass media campaigns to increase HIV testing and reduce smoking. Voucher schemes or conditional-cash transfers could be used to encourage birthing in facilities, since in highest mortality settings only half of all births take place in birthing facilities. Extra training and education could be given to community workers and ultimately pregnant women. The authors of this paper also note that quality care is not the only issue; it's also a matter of getting women to that care. Many stillbirths occur due to the delay women can experience in receiving appropriate care, including delays in the recognition of high-risk maternal disorders, and in arranging transportation to health facilities.
The paper 4 authors conclude: "Every year, the lives of more than 1•7 million women and neonates could be saved with interventions that are known to be effective during pregnancy and birth, and more than 1 million third trimester stillbirths could be prevented with the same care, providing a triple return for every dollar invested."
The authors of paper 6 (Professor Robert Goldenberg and colleagues) discuss some high-priority research themes specific to developing countries. These include how to adapt and scale-up the most effective components of birth care, including the use of caesarean section; how to adapt and scale-up effective antenatal care, including screening for and treating infections; selecting and initiating quality improvement programmes, including mortality audits; task-shifting among and appropriate training of the healthcare workforce; mobilising communities; and improving support and reducing stigma for women who have experienced stillbirth, and their families.
EXTRA INFO ON THE SERIES, INCLUDING COUNTRY BY COUNTRY BREAKDOWNS
A spreadsheet has been prepared giving country by country breakdowns and rankings. Countries are ranked by stillbirth rate in 2009 and previously in 1995; for the number of stillbirths in 2009; and in terms of average annual rate of change 1995 to 2009. In all rankings the lowest numbers are the best.
The international comparisons use stillbirth rates at 28 weeks and later, this is because WHO uses this cut-off since babies in low-income and middle-income countries are unlikely to survive if born at 28 weeks or earlier, and the data is below this cut off is highly variable in these countries. Thus the 28-week cut off allows stillbirths to be compared across countries of all incomes.
However, local definitions in high-income countries have earlier cut-off points, and thus figures according to local definition are also included. In most high-income countries, the cut-off is 22 weeks, but the key exceptions are Australia (20 weeks), USA (20 weeks) and UK (24 weeks).
Thus some high-income countries will have two rates and total stillbirth figures: one for 28 week international comparison (lower rate and number) and one according to local definition (higher). For example, the UK's rate for 2009 is 3.5 stillbirths per 1000 total births and 2630 total stillbirths using the 28 week cut-off; but using the UK's definition of 24 week cut-off, this increases to 4100 stillbirths at a rate of 5.2 per 1000 total births.
Journal
The Lancet