Study highlights global stillbirth rates

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“Stillbirth rates in the UK are higher than in almost every other high-income country, a series of reports suggest”, reported BBC News. It said that the UK had about 4,100 stillbirths in 2009, with a rate of 3.5 per 1,000 births. The UK ranked 33rd in a list of 193 countries, with only France and Austria having higher rates among the 35 high-income nations examined.

Many newspapers have reported on a series of articles about stillbirth published in the medical journal, The Lancet. The series is made up of articles and opinion pieces from experts from around the world and includes the first comprehensive data to be published on the subject. The series is introduced by an executive summary, which includes the main findings of the series and consensus statements from its authors. Proposals are given for how the rate of stillbirth can be reduced both in developing and high-income nations.

One of the research articles looked at rates of stillbirth in 193 countries. This study found that the UK was ranked 33rd, with a higher stillbirth rate than many other high-income countries, such as Norway, Denmark, Germany, Spain, Italy, Ireland and the USA. Specific reasons for the UK’s performance are not addressed, but the series suggests several factors that can increase risk of stillbirths in richer nations, including social (such as poverty), medical (placental problems) and lifestyle (smoking and obesity) factors.

A list of proposals to reduce stillbirth rates in high-income countries such as the UK was drawn up. These include measures to improve the health and wellbeing of women in pregnancy and, in particular, that of disadvantaged women and those with pre-existing disorders such as diabetes. Better detection and management of women at increased risk is needed, as are programmes to help reduce risk factors such as obesity and smoking, and improvements in information and standards of maternity care. Research is also needed into medical problems such as placental dysfunction.

The news is based on a special series of articles on stillbirth, published in the peer-reviewed medical journal, The Lancet. The 16 articles were written by an international team of 69 authors, from more than 50 organisations and 18 countries. There is also an executive statement that states the conclusions of the combined research, and consensus statements that represent the views of the authors.

The series addresses stillbirth rates and causes in all countries and sets out key actions to be implemented by 2020. These, reportedly, could halve the number of stillbirths worldwide.

A stillbirth is defined as the death of a baby in the weeks before birth, or during labour and birth. Cut-off points vary, with the World Health Organization (WHO) defining a stillbirth as the death of a baby at 28 weeks of pregnancy or later, while the UK normally defines stillbirth as a death at 24 weeks or later, and other high-income countries use a cut-off date of 22 weeks. In this report, both definitions are used, with the WHO definition used for international comparisons.

The work leading to the series took more than two years to complete and was primarily funded by the Bill and Melinda Gates Foundation in the USA.

The series of articles published the latest data on stillbirth, revealing that there are more than 2.6 million stillbirths worldwide each year (a figure that rises by 45% when the lower 22-week cut-off point is used). Most (98%) of these deaths occur in low- and middle-income countries.

The rates of stillbirth in high-income countries have changed little in recent years and, overall, about one baby in every 200 will be stillborn. This figure is based on a cut-off point of 22 weeks (in the UK, stillbirth is considered to be death after 24 weeks of pregnancy, and prior to this time deaths are classed as miscarriage). Variations in stillbirth rates both across and within rich countries reportedly show that a reduction in rates for many high-income countries is still possible.

Causes of stillbirth include complications during labour, maternal infections, high blood pressure in the mother (e.g. pre-eclampsia), diabetes and foetal growth restriction. Worldwide, two-thirds of stillbirths happen in rural areas, where skilled birth attendants are not always available during childbirth, and at least half take place during labour and birth.

The Lancet says that despite these high numbers of potentially avoidable deaths, stillbirths are still in “the shadows” in terms of global and national health agendas. It says that stillbirths are not even included in national registration systems in some countries and their prevention is often not included in international goals for maternal and child health. Similarly, stillbirth is often seen as inevitable and, in many poorer societies, stillborn babies are disposed of without recognition or funeral rites. Yet, to parents, The Lancet says, a stillbirth is no less of a tragedy than the death of a baby or child.

The series includes an analysis that looked at national, regional and worldwide stillbirth trends from 1995 to 2009 (measured with a 28-week cut-off point). It ranked 193 countries for stillbirth rates (with the country ranked 1st having the lowest rate). In 2009 the UK was ranked as 33rd with 3.5 stillbirths per 1,000 births, while in 1995 the UK’s ranking was 26th. Although the 2009 ranking appears to be worse than in 1995, the rate of stillbirths in 1995 was actually slightly higher than in 2009, at a rate of 4 stillbirths per 1,000.

The country with the highest stillbirth rate in 2009 was Pakistan (47 per 1,000 births) and the country with the lowest was Finland (2 per 1,000 births). Other countries with relatively low stillbirth rates included Norway, Denmark and Singapore. France was ranked 41st (i.e. they had a higher rate of stillbirths than the UK), Spain 25th, Italy 11th, the USA 17th and Germany 6th.

The UK does not have the worst stillbirth rate in the world, as claimed by some newspaper headlines, but it does seem to have one of the highest rates among rich nations. There are also, reportedly, wide variations within the UK. The BBC reports one of the authors saying that stillbirths are a third more likely in the East Midlands than in the South West.

The Lancet series covers global data and does not specifically focus on the UK. Therefore, the reasons why there may be a discrepancy in rates between the UK and other high-income countries have not been addressed.

The Lancet says that, among rich nations, many stillbirths are unexplained, but this is often because investigations into their causes are inadequate. It says that stillbirth may be caused by placental problems (thought to cause 25% of stillbirths), infection (thought to cause 12%) and other disorders such as cord abnormalities and accidents in the mother, high blood pressure and diabetes.

It also says that some ethnic and lower-income groups in developed nations have higher stillbirth rates than the national average, indicating that poverty and deprivation are risk factors for stillbirth.

Obesity also seems to play a role. A systematic review included in the series looking at risk factors for stillbirth found that in high-income countries, the most important modifiable risk factors for stillbirth were maternal overweight and obesity.

Other important modifiable risk factors included advanced maternal age (over 35 years) and maternal smoking. First pregnancies were more susceptible to stillbirths, and medical risk factors included pregnancies where the baby was small size for gestational age, where the placenta separated from the wall of the uterus, or where the mother had diabetes or hypertension.

In high-income countries such as the UK, the report recommends improvements in the health and wellbeing of women in pregnancy and, in particular, that of disadvantaged women and those with pre-existing disorders such as diabetes. Better detection and management of women at increased risk is needed, as are programmes to help reduce risk factors such as obesity and smoking, and improvements in information and standards of maternity care.

Research is needed into medical problems such as placental dysfunction, and also more thorough investigations into the pathology of stillbirth are needed, as well as improved data on numbers and causes. Other areas that need attention are the increase in numbers of multiple births and in pregnancies among older women.

For poorer countries, the reports propose 10 interventions that it says could halve the number of stillbirths. They include the provision of care during childbirth, in particular emergency obstetric care, folic acid fortification, prevention of malaria, and detection and treatment of syphilis, diabetes and foetal growth restriction.

The executive summary states that:

“For countries with a current stillbirth rate of more than 5 per 1,000 births, the goal by 2020 is to reduce their stillbirth rates by at least 50% from the 2008 rates. For countries with a current stillbirth rate of less than 5 per 1,000 births, the goal by 2020 is to eliminate all preventable stillbirths and close equity gaps.”

To realise this vision, the authors ask that a raft of changes are introduced internationally, within countries, and down to the community and family level. These include steps such as including stillbirth in all relevant international health reports, collating accurate data on the rate and cause of stillbirth and agreeing on ways to reduce stillbirths. At a local level, suggestions include reducing the stigma attached to stillbirths and providing support to those affected. These proposals can be viewed in their entirety within the executive summary.

More information on stillbirth can be found in our Health A-Z section.

SANDS (Stillbirth and Neonatal Death Society) is a charity that provides support for bereaved parents and their families.