Counting all stillbirths

The United Nations Statistics Division recommends the continuous and compulsory registration and tabulation of three vital events – births, deaths, and stillbirths – in order to obtain an accurate picture of a population’s health. This complete picture is used to facilitate evidence-based health program planning and policy development. While there are numerous incentives for timely and accurate birth and death registrations within the civil registry and vital statistics systems (CRVS), stillbirth registration efforts are often left behind. 

A mother and the fetus have a higher mortality risk than at any other stage in life once labor begins. A stillbirth is the death of a viable fetus, one that has reached a development level with the potential of surviving outside of the uterus (Figure 1). The estimated 2 million stillbirths that occurred in 2020 – approximately 5,400 stillbirths a day – reveal the substantial burden of stillbirths on a population’s mortality rates. Half of all stillbirths occur during birth. Three quarters of these are preventable with equitable access to quality care to enable early detection of at-risk pregnancies. 

Ideally, all stillbirths would have a medically certified cause of death assigned by a physician. In contexts in which the cause of a stillbirth cannot be medically certified, registration or reporting of the stillbirth is still critical. This information can inform implementation and targeting of interventions to increase access to care and decrease preventable stillbirth rates. 

Figure 1. Defining Stillbirths and Maternal and Neonatal Deaths 

Source: Lawn JE, Blencowe H, Pattinson R, et al. Stillbirths: Where? When? Why? How to make the data count?. Lancet. 2011;377(9775):1448-1463

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Addressing inequities and preventing stillbirths

Stillbirths are a measure of gender inequity, similar to maternal mortality, as women in low and middle-income countries (LMICs) have less access to quality healthcare than do men due to gender norms and inequitable distribution of decision-making power and financial resources. In 2019, 1 in 41 women in LMICs died from a maternal cause as compared with one in 3,300 women in high income countries. Stillbirths and neonatal deaths account for 4.5 million deaths each year and are the greatest burden of deaths among women, children, and adolescents in LMICs.   

As country health systems and access to prenatal and obstetric care improve, stillbirth rates decrease. As income levels increase, the burden of stillbirth decreases. Figure 2 shows that in 2019, low-income countries had a stillbirth rate of 22.7 per thousand total births, lower middle-income countries had a stillbirth rate of 17.1, upper middle-income countries had a stillbirth rate of 7, and high-income countries had a stillbirth rate of 3. The burden of stillbirths is greatest in Sub-Saharan Africa followed by South Asia with a total burden of 76.7% of all stillbirths globally in 2019. 

Figure 2. Stillbirths by Region from 2000 to 2019

Source: Hug L, You D, Blencowe H, et al. Global, regional, and national estimates and trends in stillbirths from 2000 to 2019: a systematic assessment. Lancet. 2021;398(10302):772-785

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Access to quality maternal health care is a critical factor in stillbirth inequities, in every country around the world. Preventing stillbirths requires investments that will also prevent maternal and neonatal death. This is a triple bottom line – where a single investment in maternal health leads to decreased stillbirths, maternal deaths and neonatal deaths in a country. In addition, this work is 100% aligned with sustainable development goal (SDG) 3.2: By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births.