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 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 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 Jennifer Zeitlin, Institute of Health and Medical Research (INSERM), France Zhengfan Wang, University of Massachusetts, Amherst Miranda Fix, University of Washington 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. Photo credits Cover page: © UNICEF/UN0283747/Tanhoa Copyright © 2020 by the United Nations Children’s Fund ISBN: 978-92-806-5141-6 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 reviewed by countries through a country consultation process but are not necessarily the official statistics of United Nations Member States, which may 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 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. United Nations Children’s Fund World Bank Group 3 UN Plaza, New York, New York, 10017 USA 1818 H Street, NW, Washington, DC, 20433 USA World Health Organization United Nations Population Division Avenue Appia 20, 1211 Geneva 27, Switzerland 2 UN Plaza, New York, New York, 10017 USA A Neglected Tragedy The global burden of stillbirths Report of the UN Inter-agency Group for Child Mortality Estimation 2020 TABLE OF CONTENTS 1 A GLOBAL HEALTH PROBLEM 9 ENORMOUS BURDEN AND LOSS 20 SLOW PROGRESS IN PREVENTING STILLBIRTHS 31 THE FUTURE WE WANT THE WAY FORWARD: ESSENTIAL ACTIONS 41 AND RECOMMENDATIONS 53 ANNEX A woman experiencing labour pain from West Bengal, India, waits for the doctor. © UNICEF/UNI194346/Kaur A GLOBAL HEALTH PROBLEM 3 A Global Health Problem One stillbirth occurs every 16 seconds. This means to 0.38. In sub-Saharan Africa, the number of that every year, about 2 million babies are stillborn. stillbirths is rising: They increased from 0.77 million This loss reaches far beyond the loss of life. The in 2000 to 0.82 million in 2019, as the growth in total psychological costs, such as maternal depression, are births outpaced the decline in the region’s stillbirth profound, not to mention the financial consequences rate. And in some high-income countries – despite for parents and long-term economic repercussions very low levels of neonatal mortality – more stillbirths for society.1 Though the difficult impacts on families than neonatal deaths occur, and in some cases, even – and most especially on women – are severe and surpass the number of infant deaths. long lasting, stigma and taboo hide the hardship of stillbirths, even in high-income countries.2 Slow progress in preventing stillbirths means the losses have been enormous. In the past two But this traumatic loss of life remains a neglected decades, the world suffered a total of 48 million issue. Stillbirths are largely absent in worldwide data stillbirths. If current trends continue, an additional 20 tracking, rendering the true extent of the problem million stillbirths will take place before 2030, placing hidden. They are invisible in policies and programmes immense and unjust strain on women, families and and underfinanced as an area requiring intervention. society. Targets specific to stillbirths were absent from the Millennium Development Goals (MDGs)3 and are Preventable losses still missing in the 2030 Agenda for Sustainable Development.4 Why are we losing so many babies before they take their first breath? Why is progress in reducing the A growing public health issue stillbirth rate so slow? There are a variety of reasons: absence of or poor quality of care during pregnancy Over the past two decades, progress in lowering the and birth; lack of investment in preventative stillbirth rate has not kept pace with achievements interventions and the health workforce; inadequate in saving mothers’ lives or those of newborns in the social recognition of stillbirths as a burden on families; first 28 days of life. In the first two decades of this measurement challenges and major data gaps; 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 cent reduction in neonatal mortality and 4.3 per cent Development Goals (SDGs). among children aged 1–59 months.5 Meanwhile, between 2000 and 2017, maternal mortality What makes these deaths even more tragic is that decreased by 2.9 per cent.6 the majority could have been prevented with high- quality monitoring and care antenatally7 and at birth.8, Available data demonstrate that stillbirths are an 9, 10 Over 40 per cent of all stillbirths occur during increasingly critical global health problem. In 2000, labour – a loss that could be avoided with improved the ratio of the number of stillbirths to the number of monitoring and timely access to emergency obstetric under-five deaths was