Stillbirths: targets, where, why and what to do?

HANNAH BLENCOWE: Stillbirths. Targets, where, why, and what to do?

In 2014, the Every Newborn Action Plan set a target to end preventable stillbirths by 2030. The target was a national stillbirth rate of 12 or less stillbirths per 1,000 total births in every country by 2030. As we can see in this graph here, the green line at the top shows the global stillbirth rate, which, in 2015, was 18.4, and the protection where it’ll be by 2030 if no action is taken. The annual rate of reduction between 2000 and 2015 was 1.9%. To reach the target by 2030, an annual rate of reduction of 4.2%. So this is a large increase.

However, 94 countries have already met the stillbirth rate of 12 or fewer per 1,000 births. They must close their equity gaps so that each woman and her child in their country has the same chance of survival. Around 60 countries need to more than double their current progress.

Many high-burden countries have set out Newborn Action Plans to increase the investment in action to end these preventable deaths. More than 80% of high-burden countries have set neonatal mortality targets to reach by 2030. But only 30% have set a stillbirth rate target.

This needs to change if we’re going to close this gap and end preventable stillbirths by 2030. So stillbirths. Where are they happening, when are they happening, and why are they happening? In 2015, there were an estimated 2.6 million stillbirths. As we can see on the map here, 10 countries account for 2/3 of stillbirths globally.

This map shows stillbirth rates. The darker the shading, the higher the stillbirth rates. And here we can see big differences between countries, with the rates have lower than five in most high-income settings, and rates as high as 30 or 40 in parts of sub-Saharan Africa. Particularly those affected by conflict.

So when are the 2-point million stillbirths occurring? Well, overall, there are 5.1 million stillbirth and neonatal deaths. Around half of all stillbirths, 1.3 million deaths, are occurring before the onset of labour.

A further half, or 1.3 million stillbirths, occurred during labour, with just under a million neonatal deaths on the day of birth. And a further 1.6 million neonatal deaths in the rest of the first month of life.

So why are 2-point million stillbirths dying each year? Well, important causes globally, including infections, such as syphilis, Group B strep, and malaria; intrapartum obstetric, or childbirth complications; antepartum haemorrhage; maternal conditions which affect the placenta and foetal growth, such as hypertension, diabetes; and congenital and genetic conditions. There are, however, challenges with comparing cause of death across different settings. There are more than 50 different classification systems for stillbirth currently in use. And while we have differences in rigour of investigation between sites, the results may not be comparable, even if we use the same classification system. Because of these reasons, no global estimates are currently possible.

However, from the evidence that we have, we know that most stillbirths are preventable. This figure here shows the population attributable risk for stillbirth for seven major modifiable risk factors globally. As we can see, deaths from maternal infections and non-communicable diseases are largely preventable, with very few deaths due to congenital causes.

So if the majority of these deaths are preventable, what must we do to end preventable stillbirths by 2030? First of all, we must invest in every mother and every baby, including stillbirths. This is investing in the girl child, the adolescent woman, preconception care, and in high-quality antenatal and intrapartum care. These investments will give a quadruple return on investment, leading to fewer stillbirths, but also fewer maternal and newborn deaths. Improve child development. It’ll also improve women’s health in general and generate a substantial economic and social benefits.

In this analysis below, we show the cost of inverting a stillbirth in low middle income countries returned almost 25 times by the economic and social value these live children would bring their families, communities, and nations.

An important part of this investment must be improving the quality of care for every mother and every newborn along the continuum of care. This includes preconception with equitable access to family planning and folic acid supplementation or fortification, quality antenatal care, including detection and management of maternal complications in pregnancy, such as infections, especially syphilis and malaria, hypertensive disorders of pregnancy, and diabetes. In addition, detection and management of foetal growth restriction.

High-quality care is also needed around the time of birth to prevent the 1.3 million antepartum stillbirths. Foetal monitoring due labour with timely response and action is required to prevent many of these deaths. In addition, in cases where pregnancy length can be adequately assessed, induction of labour if a pregnancy is lasting more than 41 weeks can prevent stillbirths. And finally, we need to count every baby, including stillbirths. This map here shows the data availability at a national level for stillbirths globally. Red indicates that stillbirths are routinely captured in national routine data systems.

The grey, dark grey indicates that there is no national data available. And the light grey indicates it’s from survey only. As we can see here, there are large gaps for stillbirth in sub-Saharan Africa and Asia. Globally, only 39 countries have high-quality data on all stillbirths at a national level. And even amongst high-burden countries, only 53% have a perinatal death review system, which includes capture of all stillbirths. We need to count every baby to make every baby count and end preventable stillbirths.