Nigeria, Democratic Republic of Congo, Ethiopia and Tanzania are in the top league of nations with high rates of stillbirths according to the first comprehensive set of stillbirth estimates, published recently in the medical journal The Lancet.
“An African woman has a 24 times higher chance of having a stillbirth at the time of delivery than a woman in a high-income country,” says Vicki Flenady, a perinatal epidemiologist, Chair of the International Stillbirth Alliance, and author of the paper on stillbirths in high-income countries for The Lancet’s Stillbirths Series.
Two-thirds of stillbirths happen in rural areas, where skilled birth attendants, in particular midwives and physicians, are not always available for essential care during childbirth and for obstetric emergencies, including caesarean sections.
The report says about 2.6 million third trimester stillbirths occur every year worldwide and it is estimated that some 1.8 million stillbirths occur in ten countries — India, Pakistan, Nigeria, China, Bangladesh, Democratic Republic of the Congo, Ethiopia, Indonesia, Afghanistan and United Republic of Tanzania. Half of all stillbirths occur in India, Pakistan, Nigeria, China and Bangladesh alone. These same countries account for a high number of maternal and newborn deaths.
Every day more than 7,300 babies are stillborn. A death occurs just when parents expect to welcome a new life.
Ninety-eight percent of stillbirths occur in low and middle-income
countries. Wealthier nations are not immune with 1 in 200 pregnancies resulting in a stillbirth – two thirds occurring in the last trimester of pregnancy, a rate that has stagnated in the last decade.
The stillbirth rate varies sharply by country, from the lowest rates of 2 per 1,000 births in Finland and Singapore and 2.2 per 1,000 births in Denmark and Norway, to highs of 47 in Pakistan and 42 in Nigeria, 36 in Bangladesh, and 34 in Djibouti and Senegal.
The five main causes of stillbirths are childbirth complications, maternal infections in pregnancy, maternal disorders (especially pre-eclampsia and diabetes), fetal growth restriction and congenital abnormalities.
If all causes of stillbirth are taken together, the new estimates would place stillbirths fifth on the list of causes of deaths worldwide, according
to The Lancet’s Stillbirths Series, authored by 69 experts from more than 50 organizations in 18 countries. The Series is comprised of six scientific
papers, two research articles, and eight linked comments.
The number of stillbirths worldwide has declined by only 1.1 percent per year, from 3 million per year in 1995 to 2.6 million in 2009. This is slower
than reductions for child and maternal mortality.
“Stillbirths often go unrecorded, and are not seen as a major public health problem,” says Flavia Bustreo, Assistant Director-General for Family and Community Health at the World Health Organization. “Yet, stillbirth is a heartbreaking loss for women and families. We need to acknowledge these losses and do everything we can to prevent them.”
Joy Lawn, Director of Global Evidence and Policy, Saving Newborn Lives/Save the Children, a lead author of The Lancet’s Stillbirths Series who coordinated the new estimates, emphasizes that “almost no burden affecting families is so big and yet so invisible both in society and on the global public health agenda.”
The number of stillbirths can be slashed, say most experts. “Stillbirths need to be an integral part of the maternal, newborn and child health agenda,” says Carole Presern, Director of The Partnership for Maternal, Newborn & Child Health (PMNCH) and a midwife. “We do know how to
prevent most of them.”
Besides lacking visibility, stillbirths lack leadership both locally and internationally. “Parental groups must join with professional organizations to bring a unified message on stillbirths to government agencies and the UN,” says J. Frederik Frøen, an epidemiologist at The Norwegian Institute of Public Health and member of the International Stillbirth Alliance.
Almost half of stillbirths, 1.2 million, happen when the woman is in labor. These deaths are directly related to the lack of skilled care at this critical time for mothers and babies.
Before-labour stillbirths account for 1.4 million deaths
Rates also vary widely within countries. In India, rates range from 20 to 66 per 1,000 births in different states. In high-income countries, disadvantaged women still have very high stillbirth rates. For example, indigenous women in Canada and Australia have stillbirth rates equal to women living in some low and middle-income countries.
Comparing 1995 to 2009 stillbirth rates, the smallest declines were reported in Sub-Saharan Africa and Oceania. Significant declines are reported for China, Bangladesh, and India, which had a combined estimate of 400,000 fewer stillbirths in 2009 than in 1995. “Stillbirth rates have halved in China and Mexico since 1995, demonstrating what can be accomplished in middle-income countries,” says Lawn.
“This Series shows that the way to address the problem of stillbirth is to strengthen existing maternal, newborn, and child health programs by focusing on key interventions, which often overlap with those interventions that benefit mothers and neonates,” says Gary L. Darmstadt, Director, Family Health Division, Global Health Program, Bill & Melinda Gates Foundation.
According to The Lancet’s Stillbirths Series, as many as 1.1 million stillbirths could be averted comprehensive emergency obstetric care Syphilis detection and treatment programme were in place.
Other interventions capable of averting stillbirths including the detection and management of fetal growth restriction, detection and management of hypertension during pregnancy, identification and induction for mothers with 41 weeks gestation.
Malaria prevention, including bednets and drugs, folic acid fortification before conception and the detection and management of diabetes in pregnancy are other courses scaling up stillbirths.
“An additional 1.6 million deaths of mothers and newborns could be averted if you add five additional interventions beyond stillbirth interventions, such as antenatal steroids and neonatal resuscitation,” says Zulfiqar A. Bhutta, Chair, Department of Pediatrics and Child Health, The Aga Khan University, Pakistan. “This is all highly doable and would save 2.7 million lives — a massive achievement.”
Despite the large numbers, stillbirths have been relatively overlooked as a global public health problem. They are not included in the Millennium Development Goals for maternal and child health set by the United Nations.