Stillbirth: Lancet series.
Subject: Still-birth (Statistics)
Still-birth (Prevention)
Still-birth (Psychological aspects)
Pub Date: 11/01/2011
Publication: Name: Reproductive Health Matters Publisher: Elsevier Science Publishers Audience: General Format: Magazine/Journal Subject: Family and marriage; Health; Women's issues/gender studies Copyright: COPYRIGHT 2011 Reproductive Health Matters ISSN: 0968-8080
Issue: Date: Nov, 2011 Source Volume: 19 Source Issue: 38
Topic: Event Code: 680 Labor Distribution by Employer
Accession Number: 276275751
Full Text: A series in the Lancet draws attention to the huge global burden of stillbirths, and addresses the institutional, services, care and emotional burden that this carries. Stillbirth is defined as the birth of a baby with a birth weight of >500g, 22 or more completed weeks of gestation, or body length of 25 cm or more, who died before or during labour or birth.

Each year, some 2.65 million stillbirths in the third trimester of pregnancy occur worldwide. 98% of them occur in low-income and middle-income countries, and 55% in rural families in sub-Saharan Africa and south Asia. Nearly one in three stillbirths--half in low-income countries happens during labour and delivery as a result of causes often closely linked to maternal and neonatal death. Estimates for stillbirth causation and linked maternal conditions are impeded by more than 35 different classifications systems. Still, the main five causes to target for prevention are: childbirth complications; maternal infections in pregnancy; maternal conditions, especially hypertension; fetal growth restriction; and congenital abnormalities. (1)

Stillbirths remain largely invisible in health monitoring reports worldwide. Whereas motherhood has been the focus of global initiatives and interventions over the past decades, there has been a lack of focus on most mothers' own aspiration: a live baby. Stillbirth is not formally included in any of the major global disease campaigns or in any of the Millennium Development Goals, nor is it included as an indicator in the Countdown to 2015 monitoring process, unlike other adverse outcomes such as maternal and neonatal mortality, A review of lay perceptions and practices around stillbirth add to the emotional burden of woman and family. A survey of health professionals reported that 80% of stillborn babies are disposed of without being given a name by the mother and mostly without recognition, e.g. through a funeral. Three-quarters will not be held or dressed, and one in four will not be seen by the mother or by any other family member. This same survey reported that one in three stillbirths is attributed to non-medical causes such as the mother's own sins and fault, bad luck, or witchcraft. The authors call for stillbirth to be included in the global health agenda by organisations currently advancing maternal and neonatal health. They also call for education to lessen the stigma associated with stillbirth and provide bereavement support. Part of this awareness should be targeted at the substantial minority of health professionals who do not agree that stillbirth prevention should be priotitised as highly as the prevention of maternal and infant deaths, often in the false belief that few stillbirths are preventable. In fact, less than 5% of stillbirths are caused by congenital anomalies. (2)

Broad-scale implementation of intervention packages across 68 countries listed as priorities in the Countdown to 2015 report could avert up to 45% of stillbirths. Overall costs for these interventions are within the general estimates of cost-effective interventions for maternal care. A systematic review of randomised trials and observational studies identified the following interventions with sufficient evidence to recommend implementation in health systems peri-conception folic acid supplementation or fortification, malaria prevention, and improved detection and management of syphilis during pregnancy in endemic areas. Childbirth care, particularly emergency obstetric care, including caesarean section, reduces the highest number of stillbirths, and should be the first priority. Antenatal care is low cost and highly effective against stillbirths related to maternal infection and under-nutrition, and can be provided through outreach workers and services. (3,4)

Whilst the focus must be on preventable stillbirths in low-income countries, further reduction in stillbirths is possible in high-income countries, where large disparities in rates of stillbirth within these countries are largely linked to poverty and lack of educational opportunities for women. A substantial proportion of stillbirths are linked to placental pathologies and infection associated with preterm birth. Overweight, obesity and smoking are important modifiable risk factors for stillbirth. Advanced maternal age is also an increasingly prevalent risk factor. (5)

The stillbirths series ends with a call for inclusion of stillbirth as a recognised outcome in all relevant international health reports and initiatives. The series proposes three goals for high-income countries: to reduce by 2020 third trimester stillbirth rates to less than five per 1,000 births; to close equity gaps; and to eliminate all preventable stillbirths. In low-income and middle-income countries, the goal is to reduce stillbirths by at least 50%. (6)

(1.) Lawn JE, Blencowe H, Pattinson R, et al. Stillbirths: Where? When? Why? How to make the data count? Lancet 2011;377:1448-63.

(2.) Froen JF, Cacciatore J, McClure EM, et al. Stillbirths: why they matter. Lancet 2011;377:1353-66.

(3.) Bhutta ZA, Yakoob MY, Lawn JE, et al. Stillbirths: what difference can we make and at what cost? Lancet 2011;377:1523-38.

(4.) Pattinson R, Kerber K, Buchmann E, et al. Stillbirths: how can health systems deliver for mothers and babies? Lancet 2011;377:1610-23.

(5.) Flenady V, Middleton P, Smith GC, et al. Stillbirths: the way forward in high-income countries. Lancet 2011;377:1703-17.

(6.) Goldenberg RL, McClure EM, Bhutta ZA, et al. Stillbirths: the vision for 2020. Lancet 2011;377: 1798-805.

DOI: 10.1016/S0968-8080(11)38593-X
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