Key messages
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98% of the
As indicated in the second paper of The Lancet's Stillbirths Series,1 stillbirths are one of the most important, yet most poorly understood and recognised adverse outcomes of pregnancy. Global estimates indicate that in 2008, at least 2·65 million (uncertainty range 2·08 million to 3·79 million) stillbirths occurred in the last trimester of pregnancy, with more than 45% in the intrapartum period. The vast majority (98%) of these stillbirths occurred in low-income and middle-income countries.1, 2 This figure approximates the total number of early neonatal deaths and is almost equal to the number of deaths in children aged 1–5 years (3·2 million).3 Despite having enormous social and health implications for both parents, stillbirths have been invisible in policies and programmes worldwide, with little recognition of potential strategies for intervention. Stillbirths are not included in tracking of the Millennium Development Goals. Moreover, most countries do not include stillbirths in their vital statistics reporting systems and, even in the countries that do, stillbirths are generally under-reported.
A major reason for stillbirths not being included in the worldwide policy agenda is the notion that little can be done at scale in developing countries. Although efforts have focused attention on the problem in its various dimensions, not much energy has been devoted to systematically assessing whether interventions work and, importantly, whether they are affordable and implementable in low-income and middle-income countries. We undertook a systematic review of evidence for the reduction in stillbirths with a range of potential interventions, and estimated the potential effects and costs if such interventions were implemented at scale in countries with the highest burden. Finally, we used the methods developed by the Child Health and Nutrition Research Initiative (CHNRI) to draw up a list of research priorities with respect to interventions to prevent stillbirths.
We systematically updated our previous reviews4, 5, 6 of evidence related to interventions that could reduce the burden of stillbirths by comprehensively updating our search for published reports to incorporate new relevant studies, and application of stringent literature review criteria developed by the Child Health and Epidemiology Reference Group (CHERG).7 Detailed search strategies for individual interventions and packages are available from the authors on request.
Key messages 98% of the
We selected a set of interventions from the range reviewed for potential assessment of effect on antenatal or intrapartum stillbirths in developing countries (panel 1). Several selected interventions are already part of the existing set of recommended intervention packages for addressing maternal and neonatal outcomes, including periconceptional folic acid supplementation, screening and management of syphilis, prevention and treatment of malaria during pregnancy in endemic areas, skilled care
We estimated total costs of the interventions individually and in combination. First, detailed lists were drawn up of the type and amount of drugs, supplies, and personnel time needed for each intervention, based on standard WHO protocols and expert opinion. The cost of these items was then estimated from international drug prices (supplied by the UNICEF supply catalogue,86 and the Management Sciences for Health international drug price indicator87) and country-specific salary data from the
In view of the lack of interest and investment in research on interventions to reduce stillbirths, we aimed to identify the highest priority areas of research with the method developed by CHNRI89 and expansion of a preliminary exercise undertaken during meetings of the Global Alliance for Prevention of Prematurity and Stillbirths (GAPPS) in 2009.6 In the CHNRI method, experts are canvassed and consulted, and their opinions are used to give priority ratings to several research questions that
We identified few studies in which interventions clearly reduced stillbirths. In particular, almost no studies reported disaggregated data for antepartum or intrapartum stillbirths, and only one study was an effectiveness trial.93 These limitations impede definitive judgment of the effectiveness of interventions that benefit both mothers and neonates. For several interventions, especially those that relate to serious maternal and neonatal complications and comprehensive emergency obstetric
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