EMBARGOED until 8 October 2020 GMT 00:01 am
A Neglected Tragedy The global burden of stillbirths
Report of the UN Inter-agency Group for Child Mortality Estimation, 2020
UnUnitedited Natatioionsns This report was prepared by Danzhen You, Lucia Hug and Anu Mishra at the United Nations Children’s Fund (UNICEF); Hannah Blencowe at the London School of Hygiene & Tropical Medicine; and Allisyn Moran at the World Health Organization (WHO). It was prepared on behalf of the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) and its Core Stillbirth Estimation Group (CSEG).
Organizations and individuals involved in stillbirth estimation work
UN IGME agencies United Nations Children’s Fund Lucia Hug, Anu Mishra, Sinae Lee, Danzhen You
World Health Organization Allisyn Moran, Kathleen Louise Strong, Bochen Cao
World Bank Group Emi Suzuki
United Nations, Department of Economic and Social Affairs, Population Division Victor Gaigbe-Togbe
Core Stillbirth Estimation Group, UN IGME Technical Advisory Group, UN IGME Leontine Alkema, University of Massachusetts, Amherst Leontine Alkema, University of Massachusetts, Amherst Dianna M. Blau, Centers for Disease Control and Prevention (United States) Robert Black, Johns Hopkins University Hannah Blencowe, London School of Hygiene & Tropical Medicine Simon Cousens, London School of Hygiene & Tropical Medicine Simon Cousens, London School of Hygiene & Tropical Medicine Trevor Croft, Demographic and Health Surveys (DHS) Program, ICF A Neglected Tragedy Andreea Creanga, Johns Hopkins University Michel Guillot, University of Pennsylvania and French Institute for Trevor Croft, Demographic and Health Surveys (DHS) Program, ICF Demographic Studies (INED) Kenneth Hill (Chair), Stanton-Hill Research Kenneth Hill (Chair), Stanton-Hill Research K. S. Joseph, University of British Columbia and the Children’s Bruno Masquelier, University of Louvain The global burden of stillbirths and Women’s Hospital and Health Centre of British Columbia Colin Mathers, University of Edinburgh Salome Maswime, University of Cape Town Jon Pedersen, Mikro! Elizabeth McClure, RTI International Jon Wakefield, University of Washington Robert Pattinson, University of Pretoria Neff Walker, Johns Hopkins University Jon Pedersen, Mikro! Others Lucy K. Smith, University of Leicester Report of the UN Inter-agency Group for Jennifer Zeitlin, Institute of Health and Medical Research (INSERM), France Zhengfan Wang, University of Massachusetts, Amherst 2020 Miranda Fix, University of Washington Child Mortality Estimation
Special thanks to the Bill & Melinda Gates Foundation for supporting UN IGME’s stillbirth estimation work and to the foundation’s Amy Pollack, Kate Somers and Savitha Subramanian for their inputs. Thanks also to the Foreign, Commonwealth & Development Office (United Kingdom) for helping to initiate this work. In addition, many government agencies provided essential data and valuable feedback through the country consultation process.
Thanks also to the Global Network for Women’s and Children’s Health, the Euro-Peristat network, the Child Health and Mortality Prevention Surveillance program and the Alliance for Maternal and Newborn Health Improvement for providing data, to Karen Avanesyan, Chris Coffey, Jing Liu, Yang Liu, Anne Rerimoi and Zitong Wang for their support in data processing and Guiomar Bay and Helena Cruz Castanheira from the United Nations Economic Commission for Latin America and the Caribbean, Population Division for their support. Thanks also go to Emily Carter, Victoria Chou and Neff Walker from Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University for providing estimates of indirect impact of COVID-19 pandemic on stillbirths.
We would also like to extend special thanks to UNICEF and WHO field office colleagues at UNICEF for supporting the country consultations.
Special thanks also to Tedbabe Degefie Hailegebriel, Gagan Gupta and Najaf Zahra for providing valuable inputs to the report and to Vidhya Ganesh, Mark Hereward, Luwei Pearson, Yanhong Zhang, Lisa Adelson, Kurtis Albert Cooper, Karoline Hassfurter, Jacob Hunt, Yves Jaques, Laura Mhairi Anne Kerr, Daniele Olivetti, Sabrina Sidhu, David Sharrow, Anshana Ranck, Brian Sokol, Aleksi Tzatzev and Cecilia Silva Venturini at UNICEF; Anshu Banerjee, Olive Cocoman, Theresa Diaz and Ann-Beth Moller at WHO; Susannah Hopkins Leisher from the International Stillbirth Alliance; and Mary Kinney from Save the Children for their feedback and support.
Naomi Lindt edited the report. Sinae Lee laid out the report. Yasmine Hage and Baishalee Nayak fact checked the report. TABLE OF CONTENTS
Photo credits Cover page: © UNICEF/UN0283747/Tanhoa 1 A GLOBAL HEALTH PROBLEM Copyright © 2020 by the United Nations Children’s Fund ISBN: 978-92-806-5141-6 9 ENORMOUS BURDEN AND LOSS The United Nations Inter-agency Group for Child Mortality Estimation (UN IGME) constitutes representatives of the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO), the World Bank Group and the United Nations Population Division. UN IGME stillbirth estimates were SLOW PROGRESS IN PREVENTING STILLBIRTHS reviewed by countries through a country consultation process but are not necessarily the official statistics of United Nations Member States, which may 20 use a single data source or alternative rigorous methods. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of 31 THE FUTURE WE WANT UNICEF, WHO, the World Bank Group or the United Nations Population Division concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. THE WAY FORWARD: ESSENTIAL ACTIONS United Nations Children’s Fund World Bank Group 41 AND RECOMMENDATIONS 3 UN Plaza, New York, New York, 10017 USA 1818 H Street, NW, Washington, DC, 20433 USA ANNEX World Health Organization United Nations Population Division 53 Avenue Appia 20, 1211 Geneva 27, Switzerland 2 UN Plaza, New York, New York, 10017 USA A GLOBAL HEALTH PROBLEM
A woman experiencing labour pain from West Bengal, India, waits for the doctor. © UNICEF/UNI194346/Kaur 3 A Global Health Problem A Neglected Tragedy: The global burden of stillbirths 4
One stillbirth occurs every 16 seconds. This means to 0.38. In sub-Saharan Africa, the number of A call to action from routine registration despite functioning that every year, about 2 million babies are stillborn. stillbirths is rising: They increased from 0.77 million systems. While household surveys provide important This loss reaches far beyond the loss of life. The in 2000 to 0.82 million in 2019, as the growth in total The health community recognizes the urgent need to information on child mortality, most suffer from psychological costs, such as maternal depression, are births outpaced the decline in the region’s stillbirth prevent stillbirths; the issue has become an essential substantial data quality issues when it comes to 13 profound, not to mention the financial consequences rate. And in some high-income countries – despite part of global child survival initiatives and goals. stillbirth. Omission of events and misclassification for parents and long-term economic repercussions very low levels of neonatal mortality – more stillbirths The United Nations’ Global Strategy for Women’s, between stillbirths and early neonatal deaths 1 for society. Though the difficult impacts on families than neonatal deaths occur, and in some cases, even Children’s and Adolescents’ Health (2016–2030) are common, posing challenges to accurate – and most especially on women – are severe and surpass the number of infant deaths. includes stillbirths in its vision, “An end to preventable measurement. In addition, the definition of stillbirth long lasting, stigma and taboo hide the hardship of maternal, newborn, child and adolescent deaths and varies across settings and over time, limiting data 2 stillbirths, even in high-income countries. Slow progress in preventing stillbirths means stillbirths”, and urges for stillbirths to be prioritized.11 comparability. Measures to improve the accuracy of the losses have been enormous. In the past two The Every Newborn Action Plan (ENAP), which was stillbirth data are needed in all settings. But this traumatic loss of life remains a neglected decades, the world suffered a total of 48 million endorsed by 194 WHO Member States, calls for each issue. Stillbirths are largely absent in worldwide data stillbirths. If current trends continue, an additional 20 country to achieve a rate of 12 stillbirths or fewer per Poor data availability and quality require innovative tracking, rendering the true extent of the problem million stillbirths will take place before 2030, placing 1,000 total births by 2030 and to reduce equity gaps, methodological work to understand the global hidden. They are invisible in policies and programmes immense and unjust strain on women, families and particularly in countries that have already met the picture of stillbirths. The UN Inter-agency Group and underfinanced as an area requiring intervention. society. stillbirth target.12 for Child Mortality Estimation (UN IGME), together Targets specific to stillbirths were absent from the with its Technical Advisory Group and Core Stillbirth 3 Millennium Development Goals (MDGs) and are Preventable losses The stillbirth rate is a sensitive indicator of quality of Estimation Group, has developed robust methods still missing in the 2030 Agenda for Sustainable care in pregnancy and childbirth and a marker of a to estimate stillbirths. Though these estimates are 4 Development. Why are we losing so many babies before they take health system’s strength.2 International organizations, vital to addressing the neglected burden of stillbirths, their first breath? Why is progress in reducing the governments and other partners must act urgently to in many countries, they remain highly uncertain. A growing public health issue stillbirth rate so slow? There are a variety of reasons: avert stillborn deaths and ensure that every woman Precise, high-quality and complete data on stillbirths absence of or poor quality of care during pregnancy is being supported through pregnancy and childbirth are needed to develop and evaluate targeted national Over the past two decades, progress in lowering the and birth; lack of investment in preventative by trained health care providers. Stakeholders can strategies. Without these data, the efficacy of policy stillbirth rate has not kept pace with achievements interventions and the health workforce; inadequate demand health care for all to fulfil the promise of initiatives cannot be shown, depriving citizens of the in saving mothers’ lives or those of newborns in the social recognition of stillbirths as a burden on families; universal health coverage and help keep every child information they need to advocate for better health first 28 days of life. In the first two decades of this measurement challenges and major data gaps; alive. and social policies and protect their families. century, the annual rate of reduction in the stillbirth absence of global and national leadership; and no rate was just 2.3 per cent, compared to a 2.9 per established global targets, such as the Sustainable The need for high-quality data The overlooked tragedy of stillbirths demands cent reduction in neonatal mortality and 4.3 per cent Development Goals (SDGs). urgent attention. To prevent stillbirths, we need 5 among children aged 1–59 months. Meanwhile, Timely, accurate recording and counting of stillbirths to provide data and evidence to answer various between 2000 and 2017, maternal mortality What makes these deaths even more tragic is that is essential to understanding the scale and geographic questions. Where are stillbirths occurring? Where 6 decreased by 2.9 per cent. the majority could have been prevented with high- distribution of the problem and working to solve it. has progress been made? Which countries must 7 8, quality monitoring and care antenatally and at birth. However, many countries do not have a functioning accelerate progress? What must be done to stop this 9, 10 Available data demonstrate that stillbirths are an Over 40 per cent of all stillbirths occur during health management information system (HMIS) unnecessary loss of life? By outlining the picture of increasingly critical global health problem. In 2000, labour – a loss that could be avoided with improved or civil registration vital statistics system to collect the global burden of stillbirths, this UN IGME report the ratio of the number of stillbirths to the number of monitoring and timely access to emergency obstetric these data; in other settings, stillbirths are excluded sets out to answer these questions and inform the under-five deaths was 0.30; by 2019, it had increased care when required. way forward. STILLBIRTH: Key facts and figures
The burden of stillbirths is enormous, but overlooked. Acceleration in progress is urgently needed. Acceleration in progress is urgently needed.
Globally, Globally,1 baby 1is baby stillborn is stillborn every every 16 16 seconds seconds nearly 4 every minute over 200 every hour 56 countries are at risk to miss the ENAP target of nearly 5,400 every day 12 or fewer stillbirths per 1,000 total births by 2030 nearly 164,000 every month nearly 2 million a year
3 in 4 stillbirths LowLow and andlower-middle lower-middle In the past two decades, Three in four stillbirths Low and lower-middle income In the past two decades 3 in 4 stillbirths 48 million babies occur occur inin sub-Saharan sub-Saharan Africa countriescountriescountries account account account for for 85% for occur in sub-Saharan were48 million stillborn babies Africa oror Southern Southern Asia Asia 84%of 85%all of stillbirthsall of stillbirths all stillbirths were stillborn Africa or Southern Asia 20 million babies areIf projectedcurrent trends to be continue stillborn 19 in million the next decade, if trendsbabies observed are projectedbetween 2000to be stillbornand 2019 in 2030 the next decade but butonly only 65% 62% of of all all live live births in reducing the stillbirth rate continue
The burden of stillbirth is enormous, but overlooked.
Most stillbirths are Among the 20 million, 2.9 million stillbirths could be Most stillbirths are Half of the stillbirths Among the 19 million, 2.9 million Over 40% of stillbirths preventable with life-saving occur after the onset of preventable with life-saving prevented by acceleratingstillbirths progress could to be meet prevented the ENAP by interventions and labour. occur after the onset of interventionshigh-quality and healthhigh- care. target in the 56 countriesaccelerating at risk to progress miss the to goal meet targets in labour quality health care all countries
For every woman and baby, qualityFor every carewoman and and support baby, quality care and support
Note: Unless otherwise noted, statements and data refer to the year 2019 through this report. 7 A Global Health Problem A Neglected Tragedy: The global burden of stillbirths 8
How do we define stillbirths?
A stillbirth is defined as a baby born with no underestimates the real burden of stillbirths, Stillbirths, live births and neonatal deaths signs of life after a given threshold, usually since it excludes stillbirths occurring at earlier related to the gestational age or weight of the gestational ages. baby. Stillbirths are reported inconsistently 28 weeks of Onset of 22 weeks of 28 days completed across countries due to the use of different For the estimates in this report, countries were pregnancy completed Live birth from birth criteria or combinations of criteria and varying requested to provide stillbirth data using the gestation gestation thresholds in areas such as gestational age 28 week definition. To allow for international and/or birthweight. These differences make it comparison, the UN IGME adjusted the stillbirth arl e tat o ate e tat o eo atal eath difficult to compare stillbirth levels and trends rate in cases where data used a different t llb rth t llb rth across countries and calculate the global definition, e.g., birthweight. In this round of burden.14, 15, 16, 17 estimation (see Figure 1), 61 per cent of data used the criteria of 28 weeks or more of gestation, t llb rth For international comparison, UN IGME stillbirth 29 per cent of the data points were adjusted or estimates refer to “late gestation fetal deaths” reclassified toa 28 week or more definition, and as deaths occurring at or after 28 weeks of 10 per cent of data points could not be adjusted gestation, which is in-line with the International because no definition was specified or a non- Classification of Diseases.18 UN IGME standard threshold was used (e.g., 26 or more recommends using a stillbirth definition that weeks) – these data points were excluded in the uses the gestational age as the single criteria. estimation process. Among the 171 countries with Gestational age is preferred to birthweight data, about two thirds (97) provided data points About one third of stillbirth data used a different cut-off criteria and/or length criteria as it is a better predictor using the 28 week or more definition exclusively. Figure 1: Proportion of data points by criteria used in reporting on stillbirths (%) of maturity and viability, and is the most For 66 countries, data points were based on 28 1,000g and 28 weeks (0%) commonly available criteria across data sources. week and other definitions, and for eight countries 1,000g or
However, using a 28 week or more definition none of the data points could be adjusted. 500g (1%) 26 weeks (0%) any (2%) 20 weeks (1%) 26 weeks (0%)
500g or 22 24 weeks 500g or 20 weeks (3%) (2%) weeks (1%)
1,000g or not 28 weeks defined 28 weeks (5%) (4%)
(61%) 22 weeks 1,000g (5%) (6%)
7 months A stillborn baby at the Princess Christian Maternity Hospital in Freetown, Sierra Leone, wrapped in cloth and lying (8%) on a counter, awaiting burial by the family. © UNICEF/UNI85526/Asselin A woman recovers in the maternity ward of Al-Shifa Hospital in Gaza after giving birth to a full-term stillborn baby girl; doctors said the loss was induced by conflict-related stress. © UNICEF/UNI166910/d’Aki
ENORMOUS BURDEN AND LOSS Enormous global burden of stillbirths Large variations across countries
Highest stillbirth rate across countries About half of all stillbirths occur in 6 countries Nearly 2 million Every day, nearly 5,400 Globally, 1 in 72 32.2 stillbirths per 1,000 total births India Democratic Republic babies are stillborn babies are stillborn babies is stillborn 23 times higher of the Congo annually worldwide Pakistan China Lowest stillbirth rate across countries 1.4 stillbirths per 1,000 total Nigeria Ethiopia births
Substantial disparities between regions Substantial disparities between income groups
Central and Southern Asia Eastern and South-Eastern Asia Europe, Northern America, Australia Low income Lower-middle income Upper-middle income High income and New Zealand 1 in 58 is stillborn 1 in 144 1 in 321 1 in 44 is stillborn 1 in 58 1 in 143 1 in 335 34% of global stillborn babies 11% 2% 27% of global stillborn babies 57% 14% 2% 27% of global live births 21% 9% 16% of global live births 46% 29% 9%
Latin America and Northern Africa and Oceania (exc. Australia Sub-Saharan Africa the Caribbean Western Asia and New Zealand) 1 in 126 1 in 87 1 in 68 1 in 46 4% 7% less than 1% 42% 7% 8% less than 1% 27%
Note: All references to regions in this report are based on the Sustainable Development Goal regional classification
The world has suffered the tremendous loss of 48 million stillbirths in the past two decades. Large regional disparities This persistent burden resulted in around 2 million stillbirths annually in recent years – many of which might have been prevented with proper care. The loss of stillborn children is not Women in sub-Saharan Africa and Southern Asia bear Large disparities were observed across regions with experienced uniformly: National stillbirth rates around the globe ranged from 1.4 to 32.2 the greatest burden of stillbirths in the world. More different levels of income. An estimated 84 per cent than three quarters of estimated stillbirths in 2019 of all stillbirths in 2019 occurred in low- and lower- stillbirths per 1,000 total births in 2019. Sub-Saharan Africa, followed by Southern Asia, had the occurred in these two regions, with 42 per cent of the middle income countries, while those countries only highest stillbirth rate and the greatest number of stillbirths. Six countries bore the burden of global total in sub-Saharan Africa (see Figure 3) and accounted for 62 per cent of live births. High-income half of all stillbirths – India, Pakistan, Nigeria, the Democratic Republic of the Congo, China and 34 per cent in Southern Asia (see Statistical Table in countries accounted for just 2 per cent of the global Ethiopia, in order of burden (highest to lowest). Annex). In sub-Saharan Africa, the estimated stillbirth burden of stillbirths but constituted 9 per cent of live rate of 21.7 stillbirths per 1,000 total births was seven births worldwide. On average, the risk of a stillbirth times higher than the lowest regional average stillbirth was 7.6 times higher in low-income countries (22.7 rate of 3.1 found in the Europe, Northern America, stillbirths per 1,000 total births) than in high-income Australia and New Zealand region. Southern Asia had countries (3.0 stillbirths per 1,000 total births). the second highest stillbirth rate, at 17.7 stillbirths per 1,000 total births (see Statistical Table in Annex). Global scale Stillbirths are increasingly concentrated in sub-Saharan Africa Figure 3: Share of stillbirths, by Sustainable Development Goal region and national income group (2000 and 2019) In 2019, an estimated 2.0 (1.9, 2.2)* million babies 72 total births resulting in a stillborn baby, or 1 every were stillborn at 28 weeks or more of gestation, with 16 seconds. This number may be an underestimate, 3a) By Sustainable Development Goal region a global stillbirth rate of 13.9 (13.5, 15.4) stillbirths per as stillbirths are often underreported.
1,000 total births (see Figure 2). This equates to 1 in