Elsevier

The Lancet

Volume 377, Issue 9778, 14–20 May 2011, Pages 1703-1717
The Lancet

Series
Stillbirths: the way forward in high-income countries

https://doi.org/10.1016/S0140-6736(11)60064-0Get rights and content

Summary

Stillbirth rates in high-income countries declined dramatically from about 1940, but this decline has slowed or stalled over recent times. The present variation in stillbirth rates across and within high-income countries indicates that further reduction in stillbirth is possible. Large disparities (linked to disadvantage such as poverty) in stillbirth rates need to be addressed by providing more educational opportunities and improving living conditions for women. Placental pathologies and infection associated with preterm birth are linked to a substantial proportion of stillbirths. The proportion of unexplained stillbirths associated with under investigation continues to impede efforts in stillbirth prevention. Overweight, obesity, and smoking are important modifiable risk factors for stillbirth, and advanced maternal age is also an increasingly prevalent risk factor. Intensified efforts are needed to ameliorate the effects of these factors on stillbirth rates. Culturally appropriate preconception care and quality antenatal care that is accessible to all women has the potential to reduce stillbirth rates in high-income countries. Implementation of national perinatal mortality audit programmes aimed at improving the quality of care could substantially reduce stillbirths. Better data on numbers and causes of stillbirth are needed, and international consensus on definition and classification related to stillbirth is a priority. All parents should be offered a thorough investigation including a high-quality autopsy and placental histopathology. Parent organisations are powerful change agents and could have an important role in raising awareness to prevent stillbirth. Future research must focus on screening and interventions to reduce antepartum stillbirth as a result of placental dysfunction. Identification of ways to reduce maternal overweight and obesity is a high priority for high-income countries.

Introduction

In high-income countries, there is an expectation that every pregnancy will end with the birth of a healthy baby. Yet about one baby out of every 200 (who reaches 22 weeks' gestation or more) is stillborn. Public perception is that stillbirths are a thing of the past, but these are not rare events. The effect of a stillbirth on parents is devastating and long term: to many of these parents the death of their baby before birth is no less a death than is the death of any other child. As highlighted in the first paper of The Lancet's Stillbirths Series,1 families are often left with intense grief and damaging psychological and social problems for many years.

Although improvements in maternity care resulted in a dramatic reduction in stillbirth in high-income countries beginning in the 1940s, more recently, the decline has slowed or halted.2 Examination of recent trends in stillbirth rates by gestational age in the USA shows some improvements in late gestation stillbirth (28 weeks or more)3 but little reduction in the early gestational age stillbirth (figure 1).

A closer look at trends in late gestation stillbirth rates across 12 high-income countries over the past 20 years reveals substantial reductions in most of these countries. Norway and the Netherlands have shown the largest reductions (50% and 40%, respectively) during this time. Norway now has the lowest rate at 2·2 stillbirths per 1000 births and the UK the highest at 3·8 stillbirths per 1000 births across these high-income countries. Although differences in rates can relate to population characteristics, practices, and policies around registration and reporting4 (including termination of pregnancy)5 rather than quality of care, these findings suggest that further reductions in stillbirth rates are possible in many high-income countries (figure 2, see webappendix p 1 for data sources).

Key messages

  • The variation in stillbirth rates clearly shows that further reduction in stillbirth is possible in high-income countries.

  • Women from disadvantaged backgrounds continue to experience stillbirth rates far in excess of non-disadvantaged women in high-income countries and an increased focus on appropriate programmes is needed to address this disparity.

  • Maternal overweight and obesity, and smoking are the most important potentially modifiable risk factors for stillbirth in high-income country settings. Implementation of preconception care for all women could reduce these risk factors. Smoking cessation programmes in pregnancy are effective and should be implemented as part of routine care.

  • Factors relating to suboptimum professional care contribute to a substantial proportion of stillbirths. Implementation of perinatal mortality audit at the national level is an important step towards addressing quality of care.

  • Data for stillbirth are inadequate. A thorough investigation of stillbirth is essential. This includes placental histopathology for all stillbirths and parents being given the option of a high-quality autopsy. Consensus on definition and classification is needed.

  • Antepartum stillbirth related to placental dysfunction and very preterm birth are major contributors to stillbirth in high-income countries. Further research is needed on underlying mechanisms to aid early detection and effective management of women at increased risk.

In the fifth paper of The Lancet's Stillbirths Series, we present priority areas for stillbirth prevention, and interventions and research to address these priorities in high-income countries. We use 500 g or more, or 22 weeks' gestation or more, to define stillbirth, unless otherwise stated.

Section snippets

Priority areas in reducing stillbirth in high-income countries

Future improvements in prevention of stillbirth must target specific causes, risk factors, and vulnerable groups. To identify priorities for stillbirth prevention, we drew on an article published alongside the Stillbirths Series,6 which presents important risk factors for stillbirth and, additionally, we undertook a detailed analysis of causes and associated disorders for stillbirths through application of one classification system to stillbirths across six high-income countries.

Interventions to reduce stillbirth in high-income countries

Interventions to prevent stillbirth have been recently reviewed64, 65, 66, 67, 68 and are summarised in the third paper of this Series.69 On the basis of these findings, we present interventions and strategies to address the priority areas identified in the first paper of this Series.1 These interventions fall into three main strategic areas: improvement of health and wellbeing of women before, during, and after pregnancy; detection and management of women at risk during pregnancy; and

Translating research into practice

As outlined above, several actions have the potential to reduce stillbirths, but uptake is often low. System barriers (especially time and resources), and barriers at the level of individual women and health professionals can be formidable. Active implementation strategies that address specific barriers to uptake are essential. For example, although brief smoking cessation interventions work, the latest NICE guidance emphasises more intensive strategies such as referral to specialist midwives

Stillbirth research priorities

Although already many opportunities for improvement exist within present evidence, significant research gaps still need to be addressed. Following the method described in the second paper of this Series,63 research themes in discovery science, epidemiology, and development and delivery were developed and scored by international working groups and the top ranking issues are summarised here. Panel 3 describes the methods used in this study.

Conclusions

Many stillbirths in high-income countries are potentially preventable. The disparity associated with disadvantaged populations requires urgent attention through improvement of living standards for women, and provision of culturally appropriate accessible antenatal care. A greater awareness of risk factors for stillbirth is needed at the community, health-care provider, and policy levels.

The absence of quality data on stillbirths is a major impediment to stillbirth prevention. The proportion of

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