Stillbirths: Epidemiology, Evidence, and Priorities for Action

doi:10.1053/j.semperi.2010.09.010

Seminars in Perinatology

Volume 34, Issue 6, December 2010, Pages 387-394

https://doi.org/10.1053/j.semperi.2010.09.010 Get rights and content

The annual global burden of stillbirths amounts to an estimated 3.2 million%, 98% of which occur in low- and middle-income countries (LMICs). Of these, 1.02 million (32%) are intrapartum, ie, taking place during labor. The most important causes of stillbirths in LMICs include obstructed or prolonged labor, hypertensive diseases of pregnancy, syphilis and gram-negative infections, malaria in endemic areas, and undernutrition. Interventions that target these causes can play an important role in reducing stillbirths. There is a clear benefit of emergency obstetrical care, particularly Cesarean delivery, on intrapartum rates in LMICs when Cesarean rates are less than 8% to 10%. Provision of a skilled birth attendant is another important intervention whereby labor complications can be prevented, identified, managed, and/or referred. Among interventions for infections, syphilis screening and treatment can prevent as many as 50% of all stillbirths in areas with high syphilis prevalence, reducing the risk of stillbirths among treated women to that of untreated women. Intermittent preventive treatment of malaria and insecticide-treated mosquito nets are also interventions with strong recommendation, especially in the first 2 pregnancies. Balanced energy protein supplementation is an important nutritional intervention to prevent stillbirths in undernourished women, especially in LMICs. Creation of increased demand for health services within communities and increasing their uptake also can play a role in averting stillbirths. Other potential social and behavioral interventions include birth spacing, smoking cessation and indoor air pollution control, although the evidence for these is weak.

Section snippets

Definition of Stillbirths

ICD-10 defines early fetal death as death of a fetus weighing 500 to 1000 g or 22 to 28 weeks' gestation and late fetal death as death of a fetus weighing at least 1000 g (or a gestational age of 28 completed weeks or a crown-heel length of 35 cm or more).⁶ The term “stillbirth” in this article refers to both early and late fetal deaths, as described in Panel 1.

Epidemiology of Stillbirths

In LMICs, the stillbirth rate (20-32 per 1000 births) is manifold higher than the rate in high-income countries (HICs; 4.2-6.8 per 1000 births), according to estimates for the year 2000.² The highest rates are in sub-Saharan Africa (32.2 per 1000 births) and South Asia (31.9 per 1000 births; Fig. 1). Reductions in stillbirth rates that have occurred during the last few decades in HICs have been primarily as the result of a reduction in stillbirths that occur during labor (ie, intrapartum

Timing of Stillbirths

Stillbirths are mainly categorized as antepartum or intrapartum, with antepartum referring to deaths occurring before the onset of labor. The other way of classification of stillbirths, particularly in LMICs in whim ultrasound or fetal monitors are largely not available, is fresh and macerated. This classification is also used in verbal autopsy data. In fresh stillbirths, the skin is intact, and there are no signs of maceration because death occurs <12 hours before delivery (equivalent to

Risk Factors and Causes of Stillbirths

Risk factors are characteristics associated with stillbirths, without an obvious direct or underlying causal relationship for stillbirth. These include previous stillbirth, short interpregnancy interval, minority status, low socioeconomic status, low level of maternal education, maternal thinness, advanced maternal age, single marital status, nulliparity, smoking, alcohol, and drug use.7, 13 An additional risk factor that is particularly pertinent in developing countries is lack of maternal

Evidence for Impact of Key Interventions

The death of an infant during the last trimester of pregnancy is a source of grief and pain for families and communities. Moreover, social taboos associated with open grieving for a stillbirth tend to make grief reactions more protracted than for early neonatal deaths.² Appropriate interventions and intervention strategies are needed to prevent stillbirths, based on evidence of benefit, especially in the world's poorest countries.1, 4 There are very few systematic reviews that have studied the

Implications of Evidence for Interventions on Program Priorities

For many interventions that are potentially effective for reducing stillbirths, data on impact on stillbirths is not available, and an alternative indicator, perinatal mortality (stillbirths plus early neonatal deaths), must be used. None of the available reviews have segregated stillbirths according to “antepartum” or “intrapartum.” This is of great significance because knowledge of the percentage of stillbirths in each category that could be averted with various interventions would greatly

Conclusions

In conclusion, this review summarizes major priorities in programs and data action to reduce stillbirths (Panel 2). More efforts need to focus on the etiology of stillbirths, whether antepartum or intrapartum, and the role of specific interventions in averting each of these 2 categories of stillbirths. The top priority for reducing stillbirths globally includes increasing and improving the coverage of skilled birth attendance and emergency obstetrical care, as these interventions have been

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Cited by (43)

Maternal PM<inf>2.5</inf> exposure associated with stillbirth: A large birth cohort study in seven Chinese cities
2021, International Journal of Hygiene and Environmental Health
Maternal exposure to fine particulate matter (PM_2.5) has been associated with a few adverse birth outcomes. However, its effect on stillbirth remains unknown in China, especially the susceptible windows and potential modifiers.
This study aimed to evaluate the associations between maternal PM_2.5 exposure and stillbirth in seven Chinese cities.
We used birth cohort data of 1,273,924 mother-and-birth pairs in seven cities in southern China between 2014 and 2017 to examine these associations. Pregnant women were recruited in the cohort at their first visit to a doctor for pregnancy, and stillbirths were recorded at the time of birth. Air pollution exposures were assessed through linking daily air pollutant concentrations from nearby monitoring stations to the mother's residential community. Cox regression models were applied to determine the associations between PM_2.5 and stillbirth for different gestational periods.
Among the participants, 3150 (2.47‰) were identified as stillbirth cases. The hazard ratio (HR) of stillbirths was 1.52 (95% CI: 1.42, 1.62) for each 10 μg/m³ increase in PM_2.5 during the entire pregnancy after controlling for some important covariates. Relatively stronger associations were observed during the second trimester [adjusted HR = 1.67 (95% CI: 1.57, 1.77)] than trimesters 1 [HR = 1.44 (95% CI: 1.37, 1.52)] and trimester 3 [HR = 1.23 (95% CI: 1.16, 1.30)]. Stratified analyses also showed a stronger association among pregnant women without previous pregnancy and previous delivery experiences.
The study indicates that maternal exposure to PM_2.5, especially during the midpoint period of pregnancy, might increase the risk of stillbirths. Maternal previous pregnancy and delivery may modify this association.
Ambient air pollution the risk of stillbirth: A prospective birth cohort study in Wuhan, China
2018, International Journal of Hygiene and Environmental Health
Citation Excerpt :
Although significant efforts have been made to reduce the occurrence of stillbirths in the past two decades, China still ranked among the top five countries with the highest number of stillbirths globally (Chen et al., 2016; Lawn et al., 2010). Stillbirth, a serious adverse pregnancy outcome, is not yet fully understood, but several studies suggest that the majority of stillbirths are preventable (Lawn et al., 2010; Yakoob et al., 2010). Thus, determining the potential risk factors associated with stillbirth in order to reduce the number of stillbirths continues to be a significant public health priority.
Recent studies suggest that ambient air pollution exposure during pregnancy is associated with stillbirth occurrence. However, the results on the associations between ambient air pollutants and stillbirths are inconsistent and little is known about the gestational timing of sensitive periods for the effects of ambient air pollutants exposure on stillbirth.
This study aimed to examine whether exposure to high levels of ambient air pollutants in a Chinese population is associated with an increased risk of stillbirth, and determine the gestational period when the fetus is most susceptible.
We conducted a population-based cohort study in Wuhan, China, involving 95,354 births between June 10, 2011 and June 9, 2013. The exposure assessments were based on the daily mean concentrations of air pollutants obtained from the exposure monitor nearest to the pregnant women’s residence. Logistic regression analyses were performed to determine the associations between stillbirths and exposure to each of the air pollutants at different pregnancy periods with adjustment for confounding factors.
Stillbirth increased with a 10 μg/m³ increase in particulate matter 2.5 (PM_2.5) in each stage of pregnancy, and a significant association between carbon monoxide (CO) exposure and stillbirth was found during the third trimester (adjusted odds ratio (aOR): 1.01, 95% confidence interval (CI): 1.00–1.01) and in the entire pregnancy (aOR: 1.18, 95% CI: 1.04–1.34). Furthermore, an increased risk of stillbirth in the third trimester was associated with a 10 μg/m³ increase in PM₁₀ (aOR: 1.08, 95% CI: 1.04–1.11), nitrogen dioxide (NO₂) (aOR: 1.13, 95% CI: 1.07–1.21) and sulfur dioxide (SO₂) (aOR: 1.26, 95% CI: 1.16–1.35). However, no positive association was observed between ozone exposure and stillbirth. In the two-pollutant models, PM_2.5 and CO exposures were found to be consistently associated with stillbirth.
Our study revealed that exposure to high levels of PM_2.5, PM₁₀, SO₂, NO₂ and CO increases the risk of stillbirth and the most susceptible gestational period to ambient air pollution exposure was in the third trimester. Further toxicological and prospective cohort studies with improved exposure assessments are needed to confirm the causal link between air pollutants and stillbirth.
Factors associated with fresh stillbirths: A hospital-based, matched, case–control study in Burkina Faso
2016, International Journal of Gynecology and Obstetrics
Citation Excerpt :
However, the effect of its routine use on perinatal and maternal morbidity and mortality is controversial [29]. Aside from use of the partograph, health systems-related factors have rarely been investigated in studies on the determinants of stillbirths compared with medical conditions and sociodemographic factors [17,30–32]. Knowledge that utilization of the partograph can significantly reduce the burden of stillbirths is of great importance in this setting because it is easy to use at any level of the health system.
To determine the risk factors for fresh stillbirths in hospitals in Burkina Faso.
A hospital-based, matched (1:1), case–control study was conducted from July to August 2014 in 50 hospitals across the country. All cases of stillbirth that occurred during this period in the participating facilities were included, and an appropriate control was selected for each case from the same health facility. Cases and controls were matched for gestational age. Conditional logistic regression with robust standard errors was used to compute both unadjusted and adjusted conditional odds ratios.
Cases were 67% less likely to have been delivered by a midwife compared with a nonmidwife attendant (ACOR = 0.33; 95% CI, 0.12–0.84; P = 0.02). Use of a partograph to monitor labor lowered the odds of fresh stillbirth by 82% (ACOR = 0.18; 95% CI, 0.05–0.61; P = 0.006). Mothers who had been transferred from another health facility were five times more likely to experience a fresh stillbirth (ACOR = 5.36; 95% CI, 2.02–14.23; P < 0.001).
Quality and timing of intrapartum obstetric care is key to preventing fresh stillbirths. Easy to implement and available interventions, such as use of a partograph for all laboring women and improving the referral system, have the potential to save the lives of many fetuses.
Global Burden, Epidemiologic Trends, and Prevention of Intrapartum-Related Deaths in Low-Resource Settings
2016, Clinics in Perinatology
Citation Excerpt :
Stillbirths may be miscounted in retrospective surveys by a margin of 20%.12 These surveys mostly rely on live birth histories and simple questions regarding stillbirths.27 In developed countries, cause-specific data related to stillbirths are available through national perinatal surveillance systems.
Proportion of stillbirth and associated factors among women who deliver at public hospitals in Bahir Dar city, north-West Ethiopia
2024, BMC Women's Health
Epidemiology of stillbirths based on different gestational thresholds at a tertiary hospital
2022, Singapore Medical Journal

View all citing articles on Scopus

View full text

Stillbirths: Epidemiology, Evidence, and Priorities for Action

Section snippets

Definition of Stillbirths

Epidemiology of Stillbirths

Timing of Stillbirths

Risk Factors and Causes of Stillbirths

Evidence for Impact of Key Interventions

Implications of Evidence for Interventions on Program Priorities

Conclusions

Lancet

Lancet

Am J Obstet Gynecol

Int J Gynecol Obstet

Lancet

Lancet

3.2 million stillbirths: epidemiology and overview of the evidence review

BMC Pregnancy Childbirth

State of the World's Children 2009Maternal and Newborn Care

These are not good things for other people to know: how women's understandings of pregnancy loss and early neonatal death in southern Tanzania may impact survey data quality

Soc Sci Med

Incorporating deaths near the Time of birth into estimates of the global burden of disease

ICD-10 International Statistical Classification of Diseases and related health problems, Tenth revision 2: Instruction Manual

Stillbirth in developing countries: a review of causes, risk factors and prevention strategies

J Matern Fetal Neonatal Med