Making visible the iniquitous impacts of stillbirth and advocating for action to reduce its incidence

Note – content below is from an email update, July 2016

The WHO refer to stillbirths as a “neglected tragedy”; 2015 rates of 18.4 per 1,000 total births are still well above the Every Newborn action Every Newborn action plan global target of 10 per 1,000 by 2035, despite falling from 24.7 in 2000. Worryingly, evidence in the 2016 “Ending Preventable Stillbirths” Lancet special edition on stillbirths indicates that the actual number of stillbirths, estimated at 2.6 million/annum, has not declined since 2011.

In this sixth informal update, HEART unpacks the new Lancet Series on Stillbirth alongside other information to highlight the relative deprioritisation of Stillbirth and outline how Quality Improvement strategies and interventions could reduce the incidence and impact in low and middle income countries (LMICs).

#1) De-prioritising the issue while inadequately monitoring the problem: The omission of stillbirths from the MDGs and SDGs indicators (although the revised Global Strategy now includes stillbirths) is seen as indicative of the low level of priority given to stillbirths.  Related to this is the lack of investment in data registration systems; less than 5% of neonatal deaths and even fewer stillbirths are registered.

#2) Confronting the (non) financial burden of stillbirth for poor and vulnerable women: Stillbirth is twice as frequent among disadvantaged women (e.g. those who are less educated, poor or from ethnic minority groups) in both low-middle income countries (LMIC) and high income countries.

Furthermore, stillbirths place a high cost (up to 70% more than a live birth), and often underrated, burden on individuals, families and communities related to funeral costs, lost income and lost productivity.  In addition to grief and loss, stillbirth can be acutely stigmatising and have an impact on mental wellbeing; an estimated 4.2 million women are living with depression following stillbirths.

#3) Understanding the incidence and causes of stillbirths: 98% of still births occur in low-middle income countries. 50% of deaths happen during labour and birth. Women who experience a near-miss (see WHO definition) in delivery are more likely to have a stillbirth.  There is a need to better understand the causes of stillbirth. Reviews estimate that up to 50% of causes of stillbirth are related to maternal factors such as syphilis, HIV, hypertension, malaria and diabetes – all preventable conditions.  Prolonged pregnancies contribute to 14% of stillbirths.  Congenital factors are less prevalent than previously thought.

#4) Preventing stillbirth through good maternal care:  Substandard care contributes to 20-30% of stillbirths. The “quadruple return” on investment in improved care i.e. reductions in maternal and newborn deaths, stillbirth and development problems have been outlined prior to 2016 e.g. in April and July 2014 Lancet editions, the WHO, and the International Society for the Study and Prevention of Perinatal and Infant Death (ISPID).

The 2016 Lancet series augments the case with its own estimates: that the provision of good quality care during pregnancy and childbirth could prevent 823,000 stillbirths, 1,145,000 newborn deaths and 166,000 deaths of pregnant women in the 75 countries with the worst stillbirth rates, at an additional cost of US$2,143 or £1,436 for each life saved. Additionally, recent research in South Africa suggests that full coverage of 13 interventions could, in a highly cost effective manner, reduce the SBR by 30% to 12.4 per 1 000 births.

#5) Outlining 2016 Lancet Series recommendations for MNH services: The Five key priorities for action highlighted by authors are:

  1. Intentional leadership – Institutions with a mandate to lead global efforts for mothers and their babies must assert their leadership to reduce stillbirths by promoting healthy and safe pregnancies.
  2. Increased voice, especially of women – To help reduce stigma and to call for more respectful and supportive care.
  3. Implementation of integrated interventions with commensurate investment – As noted there is good and growing evidence that integrated interventions can contribute to significant reductions in stillbirths. A range of best practice guidelines are available online.
  4. Indicators to measure effect of interventions and especially to monitor progress – Including effective registration systems to improve the understanding of the scope of the issue, of causal pathways and potential responses; and with which to hold governments and donors accountable. This also includes the need for standardised classification of causes of deaths to underpin the introduction of death audits.
  5. Investigation into crucial knowledge gaps – In particular a better understanding of causal pathways to reduce the high volume of unexplained stillbirths.

#6) Upcoming events / additional resources:

Please note: The resources highlighted above are just a selection of timely initiatives and recent publications – HEART does not endorse those mentioned.

Making visible the iniquitous impacts of stillbirth and advocating for action to reduce its incidence was last modified: August 8th, 2016 by Adrian Bannister