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