Making stillbirths count, making numbers talk - Issues in data collection for stillbirths (original) (raw)
Stillbirths: rates, risk factors, and acceleration towards 2030
The Lancet, 2016
There were an estimated 2.7 million third trimester stillbirths in 2015 (uncertainty range: 2.5-3.0 million). Stillbirths have reduced more slowly than maternal or child mortality, which were explicitly targeted in the Millennium Development Goals. The Every Newborn Action Plan targets ≤12 stillbirths per 1000 births in every country by 2030. Ninety-two mainly high-income countries have already met this target, although with marked disparities. At least 67 countries, particularly in Africa and conflict affected areas will have to double current progress. Most (98%) stillbirths are in low and middle-income countries. Improved care at birth is essential to prevent 1.3 million intrapartum stillbirths, end preventable maternal and neonatal deaths, and also improve child development. Estimates for stillbirth causation are impeded by multiple classification systems, but for 18 countries with reliable data, congenital abnormalities account for a median of only 7.4%. Many conditions associated with stillbirths are potentially modifiable, and often co-exist such as maternal infections (population attributable fraction (PAF): malaria 8.2%, syphilis 7.7%), non-communicable diseases, nutrition and lifestyle factors (PAF around 10%) and age>35yrs (PAF: 6.7%). Common causal pathways are through impaired placental function, either leading to fetal growth restriction and/or preterm labour, or secondary to prolonged pregnancy (PAF: 14.2%). Two-thirds of newborns have their birth registered. However, less than 5% of neonatal deaths have death registration, and even fewer stillbirths. Recording and registering all facility births, stillbirths, neonatal, and maternal deaths would substantially increase data availability. Improved data alone will not save lives, but provide a tool for targeting interventions to reach >7500 women every day all over the world who experience the reality of stillbirth. Words 266 CONFIDENTIAL-DO NOT PASS ON OR CITE 3 Key messages What is happening to stillbirth rates? At the end of the Millennium Development Goal (MDG) era there are 2.7 million (uncertainty range: 2.5-3.0 million) third trimester stillbirths annually. Stillbirth rates have declined more slowly since 2000 (Average Annual Rate of Reduction (ARR), 1.8%), than either maternal (ARR=3.4%) or post-neonatal child mortality (ARR=4.5%) which had MDG targets and consequently received more global and country level attention. Better data are essential to accelerate progress towards the target of ≤12 stillbirths per 1000 births in every country by 2030 as outlined in the Every Newborn Action Plan (ENAP), linked to United Nations Secretary General's Every Woman Every Child. Where to focus? 10 countries account for two-thirds of stillbirths and most neonatal (60%) and maternal (58%) deaths estimated in 2015. Sixty-seven countries need to at least double current progress in reducing stillbirths, many of these in Africa. The highest stillbirth rates (SBR) are in conflict and emergency areas. Over 60% of stillbirths are in rural areas, affecting the poorest families. However, even in the 92 countries with a SBR less than 12 per 1000 marked disparities remain between and within countries. When and where in the health system to focus? Each year there are an estimated 1.3 million intrapartum stillbirths (deaths during labour), despite two-thirds of births worldwide now being in health facilities. High coverage of good quality care during labour and birth is key, and would also reduce maternal and neonatal deaths, prevent disability and improve child development, giving a high return on investment. Improved quality antenatal care is also important to maximise maternal and fetal well-being, to detect and manage underlying conditions, and to promote healthy behaviours and birth planning. Which conditions to focus on? There is a myth that most stillbirths are inevitable due to non-preventable congenital abnormalities, yet for countries with reliable data congenital abnormalities account for a median of only 7.4% of stillbirths. Conditions where population attributable fraction (PAF) could be estimated at global level include: maternal age>35yrs (PAF 6.7%), maternal infections (PAF malaria 8.2%, syphilis 7.7%), non-communicable diseases, nutrition and lifestyle factors, many of which co-exist (PAF each around 10%) and prolonged pregnancy (PAF 14.2%). Stillbirths commonly occur via fetal growth restriction and/or preterm labour. Which data are required for action? Two-thirds of the world's newborns have birth certificate, but death registration coverage is even lower at <5% of neonatal deaths and even fewer stillbirths. Recording and registering all facility births, stillbirths, neonatal deaths, and maternal deaths would substantially increase data availability. Reliable measurement of stillbirths outside facilities using household surveys remains problematic, yet no research is addressing this issue. Little has been invested in improving coverage data for maternal and newborn health interventions including those specific to stillbirths. The ENAP measurement improvement roadmap, includes coverage indicator validation, and development of tools such as a minimum perinatal dataset and perinatal audit, offering opportunities to improve data availability and use.
Journal of the Turkish-German Gynecological Association
Introduction The World Health Organization (WHO) defines stillbirth as the delivery of a fetus after 22 completed weeks of gestation, weighing 500 grams or more, with the newborn showing no signs of life at delivery (1). According to the WHO, there were 2.6 million stillbirths in 2015. One out of every 45 babies was stillborn. Nearly three-quarters of them were from South Asia and sub Saharan Africa. The stillbirth rate in India was 23/1000 births in 2015, compared to a worldwide rate of 18.4/1000 births (2). Since then, the stillbirth rate in our country has declined by 10%, with an annual reduction rate of 2% between 2000-2015. This decline, however, is slow in comparison to the annual reduction in maternal mortality rate and under 5 infant mortality rate at 3% and 3.9%, respectively, during the same period (2). The WHO targets reducing the stillbirth rate to 12/1000 by 2030 by adopting the "Every newborn action plan" (2).
Stillbirth 2010–2018: a prospective, population-based, multi-country study from the Global Network
Reproductive Health, 2020
Background Stillbirth rates are high and represent a substantial proportion of the under-5 mortality in low and middle-income countries (LMIC). In LMIC, where nearly 98% of stillbirths worldwide occur, few population-based studies have documented cause of stillbirths or the trends in rate of stillbirth over time. Methods We undertook a prospective, population-based multi-country research study of all pregnant women in defined geographic areas across 7 sites in low-resource settings (Kenya, Zambia, Democratic Republic of Congo, India, Pakistan, and Guatemala). Staff collected demographic and health care characteristics with outcomes obtained at delivery. Cause of stillbirth was assigned by algorithm. Results From 2010 through 2018, 573,148 women were enrolled with delivery data obtained. Of the 552,547 births that reached 500 g or 20 weeks gestation, 15,604 were stillbirths; a rate of 28.2 stillbirths per 1000 births. The stillbirth rates were 19.3 in the Guatemala site, 23.8 in the ...
Stillbirths including intrapartum timing: EN-BIRTH multi-country validation study
BMC Pregnancy and Childbirth
Background An estimated >2 million babies stillborn around the world each year lack visibility. Low- and middle-income countries carry 84% of the burden yet have the least data. Most births are now in facilities, hence routine register-recording presents an opportunity to improve counting of stillbirths, but research is limited, particularly regarding accuracy. This paper evaluates register-recorded measurement of hospital stillbirths, classification accuracy, and barriers and enablers to routine recording. Methods The EN-BIRTH mixed-methods, observational study took place in five hospitals in Bangladesh, Nepal and Tanzania (2017–2018). Clinical observers collected time-stamped data on perinatal care and birth outcomes as gold standard. To assess accuracy of routine register-recorded stillbirth rates, we compared birth outcomes recorded in labour ward registers to observation data. We calculated absolute rate differences and individual-level validation metrics (sensitivity, speci...
Stillbirths including intrapartum timing: EN-BIRTH multi-country study
2020
Background: An estimated 2 million babies stillborn around the world each year lack visibility. Lowand middleincome countries carry 98% of the burden yet have the least data. Most births are now in facilities, hence routine register-recording presents an opportunity to improve counting of stillbirth, but research is limited, particularly regarding accuracy. This paper evaluates register-recorded measurement of hospital stillbirths, classification accuracy, and barriers and enablers to routine recording. Methods: The EN-BIRTH mixed-methods, observational study took place in five hospitals in Bangladesh, Nepal and Tanzania (2017–2018). Clinical observers collected time-stamped data on perinatal care and birth outcomes as gold standard. To assess accuracy of routine register-recorded stillbirth rates, we compared birth outcomes recorded in labour ward registers to observation data. We calculated absolute rate differences and individual-level validation metrics (sensitivity, specificity...
The Lancet, 2021
Background Stillbirths are a major public health issue and a sensitive marker of the quality of care around pregnancy and birth. The UN Global Strategy for Women's, Children's and Adolescents' Health (2016-30) and the Every Newborn Action Plan (led by UNICEF and WHO) call for an end to preventable stillbirths. A first step to prevent stillbirths is obtaining standardised measurement of stillbirth rates across countries. We estimated stillbirth rates and their trends for 195 countries from 2000 to 2019 and assessed progress over time. Methods For a systematic assessment, we created a dataset of 2833 country-year datapoints from 171 countries relevant to stillbirth rates, including data from registration and health information systems, household-based surveys, and population-based studies. After data quality assessment and exclusions, we used 1531 datapoints to estimate countryspecific stillbirth rates for 195 countries from 2000 to 2019 using a Bayesian hierarchical temporal sparse regression model, according to a definition of stillbirth of at least 28 weeks' gestational age. Our model combined covariates with a temporal smoothing process such that estimates were informed by data for country-periods with high quality data, while being based on covariates for country-periods with little or no data on stillbirth rates. Bias and additional uncertainty associated with observations based on alternative stillbirth definitions and source types, and observations that were subject to non-sampling errors, were included in the model. We compared the estimated stillbirth rates and trends to previously reported mortality estimates in children younger than 5 years. Findings Globally in 2019, an estimated 2•0 million babies (90% uncertainty interval [UI] 1•9-2•2) were stillborn at 28 weeks or more of gestation, with a global stillbirth rate of 13•9 stillbirths (90% UI 13•5-15•4) per 1000 total births. Stillbirth rates in 2019 varied widely across regions, from 22•8 stillbirths (19•8-27•7) per 1000 total births in west and central Africa to 2•9 (2•7-3•0) in western Europe. After west and central Africa, eastern and southern Africa and south Asia had the second and third highest stillbirth rates in 2019. The global annual rate of reduction in stillbirth rate was estimated at 2•3% (90% UI 1•7-2•7) from 2000 to 2019, which was lower than the 2•9% (2•5-3•2) annual rate of reduction in neonatal mortality rate (for neonates aged <28 days) and the 4•3% (3•8-4•7) annual rate of reduction in mortality rate among children aged 1-59 months during the same period. Based on the lower bound of the 90% UIs, 114 countries had an estimated decrease in stillbirth rate since 2000, with four countries having a decrease of at least 50•0%, 28 having a decrease of 25•0-49•9%, 50 having a decrease of 10•0-24•9%, and 32 having a decrease of less than 10•0%. For the remaining 81 countries, we found no decrease in stillbirth rate since 2000. Of these countries, 34 were in sub-Saharan Africa, 16 were in east Asia and the Pacific, and 15 were in Latin America and the Caribbean. Interpretation Progress in reducing the rate of stillbirths has been slow compared with decreases in the mortality rate of children younger than 5 years. Accelerated improvements are most needed in the regions and countries with high stillbirth rates, particularly in sub-Saharan Africa. Future prevention of stillbirths needs increased efforts to raise public awareness, improve data collection, assess progress, and understand public health priorities locally, all of which require investment. Funding Bill & Melinda Gates Foundation and the UK Foreign, Commonwealth and Development Office.