Slow progress on stillbirth prevention

Tue Jan 19 2016 13:00:00 GMT+1300 (New Zealand Daylight Time)

Slow progress on stillbirth prevention

19 January 2016

Professor Lesley McCowan

Maternal and child deaths have halved globally while stillbirth remains a neglected global epidemic, according to a report just published in a leading medical journal.

Four University of Auckland academics were involved in writing the fourth paper in The Lancet Series on ‘Ending Preventable Stillbirths’ that is intended to focus attention at a policy and research level on reducing the global burden of stillbirths.

More than 2.6 million stillbirths continue to occur globally every year with very slow progress made to tackle this ‘silent problem’, according to the new research.

Despite significant reductions in the number of maternal and child deaths, there was little change in the number of stillbirths (in the third trimester of pregnancy) even though many may be preventable.

World-wide, half of all stillbirths occur during labour and birth, usually after a full nine month pregnancy, and the research highlights that most of these 1.3 million deaths globally could be prevented with improved quality of care especially in developing countries.

This fourth paper in the series looks at what is going on in high income countries and examines the stillbirth rate from 2000 to 2015 in 49 counties.
New Zealand with 2.3 stillbirths (after 28 weeks of pregnancy) per 1000 births in 2015, is doing better than many countries, including Australia (at 2.7 per 1000 births). New Zealand has also had a reduction in the stillbirth rate in recent years.

One of the co-authors, the head of Obstetrics and Gynaecology at the University of Auckland, Professor Lesley McCowan, says “New Zealand is doing quite well and is tenth best in terms of our stillbirth rate for babies after 28 weeks with a small reduction in that rate in recent years. But we can still do better with research aimed to identify modifiable risk factors for stillbirth here.”

Professor McCowan provided New Zealand input into the global research along with fellow University of Auckland academics, Professor Frank Bloomfield (Director, Liggins Institute), Professor Cindy Farquhar (Post-graduate Professor, Obstetrics and Gynaecology and Dr Lynn Sadler (Population Health).

“In New Zealand we are fortunate to have very good national data collection( provided by the Perinatal and Maternal Mortality Review Committee, PMMRC) that started in 2006 and gives us detailed information about babies that have died from stillbirth. From this we can try and identify any groups more at risk and ways to reduce those risks,” says Professor McCowan.

Globally, 98 percent of all stillbirths occur in low- and middle-income countries, but the problem also remains significant in high-income countries where the number of stillbirths is now often higher than infant deaths.

The Ending Preventable Stillbirth research series states the annual rate of reduction for stillbirths is two percent, much slower than progress made for maternal (3 percent) and child deaths (4.5 percent).

It also reveals the hidden consequences of stillbirth with more than 4.2 million women living with symptoms of depression, often for years, in addition to economic loss for families and nations.

Series co-lead, Professor Joy Lawn from the London School of Hygiene and Tropical Medicine, says “We must give a voice to the mothers of 7,200 babies stillborn around the world every day. There is a common misperception that many of the deaths are inevitable, but our research shows most stillbirths are preventable.”

“Half of the 2.6 million annual deaths could be prevented with improved care for women and babies during labour and childbirth, and additionally, many more lives could be saved with effective care during pregnancy,” she says. “We already know which existing interventions save lives.”

“These babies should not be born in silence, their parents should not be grieving in silence, and the international community must break the silence as they have done for maternal and child deaths,” says Professor Lawn. “The message is loud and clear - shockingly slow progress on stillbirths is unacceptable.”

New estimates of stillbirth rates for 195 countries developed by the London School of Hygiene & Tropical Medicine with the World Health Organisation and UNICEF reveal huge inequalities around the world.

Ten countries account for two-thirds of stillbirths with India having the highest number, estimated at 592,100 in 2015. The highest rates are in Pakistan (43.1 per 1,000 total births) and in Nigeria (42.9).

The lowest rates are in Iceland (1.3), Denmark (1.7), Finland (1.7) and the Netherlands (1.8). Netherlands is also making the fastest progress, reducing stillbirths by 6.8 percent per year. The United States is one of the slowest progressing countries with a reduction of 0.4 percent per year.

In every region around the world there are countries that are out-performing their neighbours, for example Rwanda is the fastest progressing country in Africa (annual rate of reduction of 2.9 percent),demonstrating that most stillbirths are preventable and progress is achievable.

UN Secretary-General, Ban Ki-moon, says "Childbirth is one of the most risky moments of life for both mothers and babies. We must make a global push to eliminate the tragedy of the millions of mostly preventable stillbirth deaths that occur every year.”

“That is why a focus on a continuum of care, from family planning through pregnancy to birth and beyond into childhood and adolescence, is a key element of the Every Woman Every Child movement and the Global Strategy for Women's, Children's and Adolescents' Health."

The new research includes the first global analysis of risk factors associated with stillbirth, underlining that many deaths can be prevented by;

• Treating infections during pregnancy – 8.0 percent of all stillbirths are attributable to malaria, increasing to 20.0% in sub-Saharan Africa, and 7.7 percent of all stillbirths are associated with syphilis, increasing to 11.2 percent in sub-Saharan Africa.
• Tackling the global epidemics of obesity and non-communicable diseases, notably diabetes and hypertension – at least 10 percent of all stillbirths are linked to each of these conditions.
• Strengthening access to and quality of family planning services – especially for older and very young women, who are at higher risk of stillbirth.
• Addressing inequalities – in high-income countries, women in the most disadvantaged communities face at least double the risk of stillbirth.

The research also highlights the underappreciated psychological, social and economic impacts of stillbirth on parents, families, caregivers, and countries.

Key findings from the paper included that;

• Variation in stillbirth rates - Late gestation (28 weeks or more) stillbirth rates vary across high-income countries (HICs) from 1•3 to 8•8 per 1000 total births, showing that further reduction in stillbirths is possible. Setting and monitoring of targets in all HICs are important to reduce preventable stillbirths.
• Disadvantage and marginalisation - Socially marginalised and disadvantaged women often have twice or more the risk of stillbirth when compared to their more advantaged counterparts. Social determinants of maternal and fetal wellbeing should be monitored in all HICs, and addressed through education and alleviation of poverty, as well as improved access to health care, especially timely, culturally appropriate antenatal care.
• Stigma and fatalism – these continue to exacerbate trauma for families and impede progress in stillbirth prevention. Strong parent and care provider partnerships are needed to dispel misperceptions and negative attitudes that persist in communities.
• Measurement for progress - All countries have the responsibility to implement high-quality national audits for perinatal mortality, which translate into improvements in quality of care. Key performance indicators of quality maternity care should be measured and reported with the aim to eliminate substandard antepartum and intrapartum care, which is too often present when a stillbirth occurs.
• Bereavement care frequently does not meet the needs of parents, often with devastating consequences. Immediate bereavement care should be provided by appropriately trained health-care professionals with a sensitive and seamless transition to community support services in all settings.
• Access to high-quality investigation into the causes of stillbirth, including autopsy and placental histopathology by a skilled perinatal pathologist, should be made available to all parents after stillbirth. Consensus on a classification system for stillbirth, which addresses the contribution of placental pathology, and a standard definition for reporting stillbirths that makes comparison possible for reports of early and late stillbirth rates across HICs, are needed.
• Future research must focus on stillbirth prediction, understanding placental pathways to stillbirth and causal pathways to unexplained stillbirth. Effective strategies are needed to reduce the prevalence of obesity and smoking in women of reproductive ages. Understanding pathways leading to early stillbirth and spontaneous preterm birth at early gestation is also important to pursue

New estimates suggest at least 4.2 million women around the world are living with symptoms of depression due to stillbirth, suffering psychological distress, stigma and social isolation, as well as increased risk of family breakdown, and even abuse and violence.

The Ending Preventable Stillbirth Series was developed by 216 experts from more than 100 organisations in 43 countries and comprises five papers. The research provides compelling evidence of the preventability of most stillbirths, forming the basis for action from parents, health care professionals, and politicians. It follows the research group’s 2011 series on stillbirths also published in The Lancet.

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