New global and country estimates published in Lancet Series

Brazzaville, 14 April 2011 -- Some 2.6 million stillbirths occurred worldwide in 2009, according to the first comprehensive set of estimates published today in a special series of The Lancet medical journal. About a third of these still births occur in Africa where the number of still births is estimated to be around 900,000.

Every day more than 7 200 babies are stillborn ─ a death just when parents expect to welcome a new life ─ and 98% of them occur in low- and middle-income countries. High-income countries are not immune, with one in 320 babies stillborn ─ a rate that has changed little in the past decade.

The new estimates show that the number of stillbirths worldwide has declined by only 1.1% per year, from 3 million in 1995 to 2.6 million in 2009. This is even slower than reductions for both maternal and child mortality in the same period.

The five main causes of stillbirth are childbirth complications, maternal infections in pregnancy, maternal disorders (especially hypertension and diabetes), fetal growth restriction and congenital abnormalities.

When and where do stillbirths occur?

Almost half of all stillbirths, 1.2 million, happen when the woman is in labour. These deaths are di-rectly related to the lack of skilled care at this critical time for mothers and babies.

Two-thirds happen in rural areas, where skilled birth attendants ─ in particular midwives and physicians ─ are not always available for essential care during childbirth and for obstetric emer-gencies, including caesarean sections.

The stillbirth rate varies sharply by country, from the lowest rates of 2 per 1 000 births in Finland and Singapore and 2.2 per 1 000 births in Denmark and Norway, to highs of 47 in Pakistan and 42 in Nigeria, 36 in Bangladesh, and 34 in Djibouti and Senegal. Rates also vary widely within countries. In India, for example, rates range from 20 to 66 per 1 000 births in different states.

It is estimated that 66% ─ some 1.8 million stillbirths ─ occur in just 10 countries four of which are in the African Region, namely: Democratic Republic of the Congo, Ethiopia, Nigeria, and the United Republic of Tanzania. The others are India, Pakistan, China, Bangladesh, Indonesia, and Afghani-stan.

Most of the countries in the world with the highest rates of stillbirths per 1 000 live births are in the African Region, with 22 countries having rates of 25 or more stillbirths per 1 000 live births. . Nigeria has the highest rate in the African region, at 41.7 stillbirths per 1 000 births overall.

Comparing stillbirth rates in 1995 to 2009, the least progress has been seen in Sub-Saharan Africa and Oceania. However, some large countries have made progress, such as China, Bangladesh, and India, with a combined estimate of 400 000 fewer stillbirths in 2009 than in 1995. Mexico has halved its rate of stillbirths in that time.

“Many stillbirths are invisible because they go unrecorded, and are not seen as a major public health problem. Yet, it is a heartbreaking loss for women and families. We need to acknowledge these losses and do everything we can to prevent them. Stillbirths need to be part of the maternal, newborn and child health agenda,” says Dr Flavia Bustreo, WHO's Assistant Director-General for Family and Community Health.

Well-known interventions for women and babies would save stillbirths too

Stillbirths are very much related to quality of care in maternal health programmes. To address the problem of stillbirth, there is need to strengthen existing maternal health programmes by focusing on key interventions, which also have benefits for mothers and newborns.

According to an analysis to which WHO contributed in The Lancet Stillbirth Series, as many as 1.1 million stillbirths could be averted with universal coverage of the following interventions:

• Comprehensive emergency obstetric care 696 000
• Syphilis detection and treatment 136 000
• Detection and management of fetal growth restriction 107 000
• Detection and management of hypertension during pregnancy 57 000
• Identification and induction for mothers with >41 weeks gestation 52 000
• Malaria prevention, including bednets and drugs 35 000
• Folic acid fortification before conception 27 000
• Detection and management of diabetes in pregnancy 24 000

Strengthening family planning services would also save lives by reducing the numbers of unintended pregnancies, especially among high-risk women, and thereby reduce stillbirths.

Improving access to skilled birth attendance and making emergency obstetric care available would significantly decrease both maternal and neonatal mortality as well stillbirths. Africa has long way to go, as fewer than half of births (47%) are attended by skilled health workers, and only 12% of women needing emergency obstetric care getting it.

“If every woman had access to a skilled birth attendant ─ a midwife, and if necessary a physician ─ for both essential care and for procedures such as emergency caesarean sections, we would see a dramatic decrease in the number of stillbirths,” says Dr Carole Presern, Director of The Partnership for Maternal, Newborn & Child Health (PMNCH), and a trained midwife.

“Pregnancy that should normally end with a new, healthy life bringing untold joy to a mother, often-times results in tragic loss of life – either of the mother, the child or both” says Dr Luis Gomes Sambo, WHO Regional Director for Africa.

“This need not be the case. A significant improvement in the rate of skilled attendance at birth in our Region and greatly improved access to emergency obstetric care will ensure that the lives of more babies and more mothers are saved during childbirth.”

Stillbirths overlooked

Despite the large numbers, stillbirths have been relatively overlooked. They are not included in the Millennium Development Goals for improving maternal health and reducing child mortality. In most African countries, stillbirth is seldom mentioned in maternal and child health programmes, thus making it difficult to know the magnitude of the problem, let alone address it.

The estimates were generated using a statistical model that took records of births and deaths (known as 'vital registration' data) from 79 countries, surveys from 39 countries, and studies from 42 coun-tries. Weak vital registration systems, especially in the regions where most stillbirths occur, limit the availability of data and hamper the calculation of precise estimates. In the African region hardly any country has complete civil registration resources from which stillbirths can be accurately calculated. Vital registration systems must be improved so that all stillbirths are counted.

The new estimates aim to improve knowledge about the extent of the problem, and draw public and professional attention to stillbirths as a significant global public health issue.

Some 69 authors from more than 50 organizations in 18 countries wrote the six scientific papers, two research articles, and eight linked commentaries included in The Lancet Stillbirth Series, which was initiated by WHO and the Norwegian Institute of Public Health.

UN commitment

In September 2010, UN Secretary-General Ban Ki-moon announced the Global Strategy for Women’s and Children’s Health, aimed at saving 16 million women and children over the next five years. In the framework of the Strategy, numerous countries have committed to improving access to family planning, antenatal care and skilled birth attendance, which should lead to reductions in stillbirths.

In September this year, a special session on noncommunicable diseases (NCDs) will be held at the UN General Assembly. NCDs such as diabetes and hypertension (high blood pressure) are risk fac-tors for stillbirth.

For further information

Dr Triphonie Nkurunziza, WHO/AFRO,
Tel: +47 241 39312(Direct):
Email: nkurunzizat [at] afro.who.int (nkurunzizat[at]afro[dot]who[dot]int)

Sam Ajibola, WHO/AFRO
Tel: +47 241 39378(Direct)
E-mail : ajibolas [at] afro.who.int (ajibolas[at]afro[dot]who[dot]int)

Olivia Lawe-Davies, Department of Maternal, Newborn, Child and Adolescent Health, WHO
Email: lawedavieso [at] who.int (lawedavieso[at]who[dot]int); Office: + 41 22 791 1209; Mobile: +41 79 475 5545

Tammy Farrell, Partnership for Maternal, Newborn & Child Health (PMNCH)
Email: farrellt [at] who.int (farrellt[at]who[dot]int); Office: + 41 22 791 4711