Stillbirth: A report by WHO
Fahid Fayaz Darangay
A stillbirth is the death or loss of a baby before or during delivery. Both miscarriage and stillbirth describe pregnancy loss, but they differ according to when the loss occurs. In the United States, a miscarriage is usually defined as loss of a baby before the 20th week of pregnancy, and a stillbirth is loss of a baby after 20 weeks of pregnancy.
Stillbirth is further classified as either early, late, or term.
• An early stillbirth is a fetal death occurring between 20 and 27 completed weeks of pregnancy.
• A late stillbirth occurs between 28 and 36 completed pregnancy weeks.
• A term stillbirth occurs between 37 or more completed pregnancy weeks.
Factors Increasing this risk
Stillbirth with an unknown cause is called “unexplained stillbirth.” Having an unexplained stillbirth is more likely to occur the further along a woman is in her pregnancy. Having an autopsy on the baby and other laboratory tests is important in trying to understand why the baby died before birth. Your health care provider can share more information about this.
Stillbirth occurs in families of all races, ethnicities, and income levels, and to women of all ages. However, stillbirth occurs more commonly among certain groups of people including women who of black race
• are 35 years of age or older
• are of low socioeconomic status
• smoke cigarettes during pregnancy
• have certain medical conditions, such as high blood pressure, diabetes and obesity
• have multiple pregnancies such as triplets or quadruplets
• have had a previous pregnancy loss
This does not mean that every individual of black race or older age is at higher risk for having a stillbirth. It simply means that overall as a group, more stillbirths occur among all mothers of black race or older age when compared to white mothers and mothers under 35 years of age. Differences in factors such as maternal health, income, access to quality health care, stress, social and emotional support resources and cultural factors may explain how these factors are related to having a stillbirth. More research is needed to determine the underlying cause of stillbirths in these populations.
Almost 2 million babies are stillborn every year – or 1 every 16 seconds – according to the first ever joint stillbirth estimates released by UNICEF, WHO, the World Bank Group and the Population Division of the United Nations Department of Economic and Social Affairs.
The vast majority of stillbirths, 84 per cent, occur in low- and lower-middle-income countries, according to the new report, A Neglected Tragedy: The Global Burden of Stillbirths. In 2019, 3 in 4 stillbirths occurred in sub-Saharan Africa or Southern Asia.
“Losing a child at birth or during pregnancy is a devastating tragedy for a family, one that is often endured quietly, yet all too frequently, around the world,” said Henrietta Fore, UNICEF Executive Director. “Every 16 seconds, a mother somewhere will suffer the unspeakable tragedy of stillbirth. Beyond the loss of life, the psychological and financial costs for women, families and societies are severe and long lasting. For many of these mothers, it simply didn’t have to be this way. A majority of stillbirths could have been prevented with high quality monitoring, proper antenatal care and a skilled birth attendant.”
The report warns that the COVID-19 pandemic could worsen the global number of stillbirths. A 50 per cent reduction in health services due to the pandemic could cause nearly 200 000 additional stillbirths over a 12-month period in 117 low- and middle-income countries. This corresponds to an increase in the number of stillbirths by 11.1 per cent. According to modeling done for the report by researchers from the Johns Hopkins Bloomberg School of Public Health, 13 countries could see a 20 per cent increase or more in the number of stillbirths over a 12-month period.
Most stillbirths are due to poor quality of care during pregnancy and birth. Lack of investments in antenatal and intrapartum services and in strengthening the nursing and midwifery workforce are key challenges, the report says.
Over 40 per cent of stillbirths occur during labour—a loss that could be avoided with access to a trained health worker at childbirth and timely emergency obstetric care. Around half of stillbirths in sub-Saharan Africa and Central and Southern Asia occur during labour, compared to 6 per cent in Europe, Northern America, Australia and New Zealand.
Even before the pandemic caused critical disruptions in health services, few women in low- and middle-income countries received timely and high-quality care to prevent stillbirths. Half of the 117 countries analyzed in the report have coverage that ranges from a low of less than 2 per cent to a high of only 50 per cent for 8 important maternal health interventions such as C-section, malaria prevention, management of hypertension in pregnancy and syphilis detection and treatment. Coverage for assisted vaginal delivery – a critical intervention for preventing stillbirths during labour – is estimated to reach less than half of pregnant women who need it.
As a result, despite advances in health services to prevent or treat causes of child death, progress in lowering the stillbirth rate has been slow. From 2000 to 2019, the annual rate of reduction in the stillbirth rate was just 2.3 per cent, compared to a 2.9 per cent reduction in neonatal mortality, and 4.3 per cent in mortality among children aged 1–59 months. Progress, however, is possible with sound policy, programmes and investment.
The report also notes that stillbirth is not only a challenge for poor countries. In 2019, 39 high-income countries had a higher number of stillbirths than neonatal deaths and 15 countries had a higher number of stillbirths than infant deaths. A mother’s level of education is one of the greatest drivers of inequity in high-income countries.
In both low- and high-income settings, stillbirth rates are higher in rural areas than in urban areas. Socioeconomic status is also linked to greater incidence of stillbirth. For example, in Nepal, women of minority castes had stillbirth rates between 40 to 60 per cent higher than women from upper-class castes.
Ethnic minorities in high-income countries, in particular, may lack access to enough quality health care. The report cites that Inuit populations in Canada, for example, have been observed to have stillbirth rates nearly three times higher than the rest of Canada, and African American women in the United States of America have nearly twice the risk of stillbirth compared to white women.
“COVID-19 has triggered a devastating secondary health crisis for women, children and adolescents due to disruptions in life-saving health services,” said Muhammad Ali Pate, Global Director for Health, Nutrition and Population at the World Bank and Director of the Global Financing Facility for Women, Children and Adolescents. “Pregnant women need continued access to quality care, throughout their pregnancy and during childbirth. We are supporting countries in strengthening their health systems to prevent stillbirths and ensure that every pregnant woman can access quality health care services.”
In 2015, the stillbirth rate (SBR) was 18.4 per 1000 total births worldwide. The progress in reducing stillbirth since 1990 has been slower than reductions in neonatal and under-five child mortality. Currently, 98% of stillbirths occur in low-to-middle-income countries (LMICs) and India has the highest number of stillbirths, with an estimated 592?100 deaths per year, and a WHO estimated rate of 22 per 1000 total births. The Government of India has developed an Indian Newborn Action Plan which includes efforts to ’reduce stillbirths to <10 per 1000 births by 2030’. A modest reduction in India’s SBR would translate into thousands of lives saved.
While previous studies have examined the immediate pregnancy-related risk factors for stillbirth such as infections during pregnancy and hypertensive disorders, knowledge about distal risk factors such as socioeconomic, lifestyle related and comorbidities is limited. The Indian government recognises the need to improve pregnancy care and institutional delivery among disadvantaged socioeconomic groups who have a higher risk of maternal and fetal death. Since 2005, the government has made several efforts including cash assistance and dedicated services through community health workers with a stronger focus in the states with poor health and development indicators.
(The author is currently pursuing Masters in Financial Economics from Madras School of Economics, Chennai)