London School of Hygiene & Tropical Medicine

The Lancet has launched its Series on Stillbirths, with the very latest estimates showing that more than 2.6 million stillbirths occur each year - over 7,000 each day. While 98% of these occur in low-income and middle-income countries, stillbirths also continue to blight wealthy nations, with around 1 in every 320 babies stillborn in high-income countries. The Series addresses stillbirth rates and causes in all countries, and sets key actions by 2020 to halve this event that devastates parents and families.

The international team of authors is led by Dr Joy Lawn (Saving Newborn Lives/Save the Children, Cape Town, South Africa) and Vicki Flenady, Mater Medical Research Institute and University of Queensland, Australia and Chair of the International Stillbirth Alliance (ISA). The Series involves 69 authors, from more than 50 organisations and 18 countries, who have worked for over two years on the analysis. The work was primarily funded by the Bill and Melinda Gates Foundation.

The Series includes six papers, two further research Articles, and eight Comments including one from bereaved parents and one from professional organisations responsible for clinical care to reduce stillbirths.

The global picture

Around 2.6 million stillbirths occur worldwide each year during the last trimester of pregnancy (after 28 weeks' gestation), the WHO definition for stillbirths for international comparison. If a 22 week cut-off is used instead as in most high-income countries the total number of stillbirths would be about 45% higher.

Joy Lawn and colleagues including Simon Cousens and Hannah Blencowe, of the London School of Hygiene and Tropical Medicine, explore the implications of the first ever set of nationally reviewed stillbirth estimates undertaken with the WHO (paper 2). Rates of stillbirths range from 2.0 per 1000 total births in Finland to more than 40 per 1000 in Nigeria and Pakistan. In 2009, 98% of all stillbirths were in low-income and middle-income countries and more than three quarters (76%) occurred in south Asia and sub-Saharan Africa. Most high-income countries have rates less than 5 per 1000, while high burden countries have rates of 25 or more per 1000; if these highest-burden countries had rates of the same as rich nations, more than three quarters of the world's annual stillbirths would be prevented.

Rates also vary within countries, with rates in India varying from 20 to 66 per total births in different states. In high-income countries, women from disadvantaged backgrounds are much more likely to have a stillbirth, with black women in the UK, African-American women in US and Indigenous women in Australia and Canada around twice as likely as white women to experience a stillbirth - as are other women living with socioeconomic deprivation compared with those who don't.

Approximately 1.2 million stillbirths occur during birth (intrapartum) and 1.4 million before birth (antepartum). Most intrapartum stillbirths are associated with obstetric emergencies (childbirth complications) and these deaths have been virtually eliminated in high-income countries. Antepartum stillbirths are more commonly associated with maternal infections and fetal growth restriction. For example syphilis - an easily treatable cause of stillbirth - is still common in some countries. In high-income countries, obesity, smoking, and advanced maternal age are among the big risk factors.

Stillbirth rate data, estimates, and the first ever time trend analysis are discussed in one of the Articles by Simon Cousens, Joy Lawn and colleagues including from WHO. Overall, stillbirths have fallen from an estimated 3.03 million in 1995 to 2.64 million in 2009.The global stillbirth rate has been reduced from 22 stillbirths per 1000 total births to 19. This reduction of 1.1% per year since 1995 is lower than the 2.3% annual reduction in child under-5 mortality and 2.5% annual reduction in maternal mortality. In some, but not all, high-income countries the rate of progress has slowed. The three countries with the most progress in terms of reduction in stillbirths rates from 1995 to 2009 are Colombia, China and Mexico.

The Series also addresses common misconceptions, such as that stillbirth is an inevitable loss that cannot be prevented-the reality being that congenital abnormalities cause less than 5% of total global stillbirths. The fact that the risk of stillbirth increases throughout the final trimester of pregnancy (3 times greater at 40 weeks than at earlier gestational ages) is largely unrecognised.

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