Leaving no one behind: Where are 2.6 million stillbirths?
We welcome the recent BMJ collection highlighting the United Nations guiding principle “Leave no one behind”—but this collection has left someone behind: 26 million women and families who will experience a stillbirth by 2030.1,2
As representatives of affected parents, academics, clinicians and civil society organizations committed to breaking the silence on stillbirth, we agree with Dr. Tedros’ Opinion in this BMJ collection that the world may “fall short of our commitment to reach the most vulnerable populations with effective, sustainable solutions by 2030”. Indeed, the absence of a single mention of the 2.6 million annual stillbirths from this BMJ collection requires that the global health community reflect on blind spots in our commitment to women’s, children’s and adolescents’ health.
With ten years to achieve the sustainable development goals (SDGs), we cannot afford to ignore stillbirths.3 Stillbirth rates are an important indicator of quality of care in pregnancy and childbirth, and a sensitive marker of health system strength, reflecting progress towards SDG targets for increasing equity and access to Universal Health Coverage.
Stillbirths contribute a major proportion of the burden of maternal and child deaths, yet progress to reduce stillbirths has been slow, despite most being preventable through high-quality antenatal and intrapartum care within the continuum of care for women and children.4 Since 2000, the average annual rate of reduction (ARR) for stillbirths (2.0%) has been half the ARR for post-neonatal mortality of children younger than 5 years (4.4%) and slower than the reduction of maternal mortality (2.9%).5,6 Investment in interventions to prevent stillbirths will bring multiple returns, also preventing maternal and neonatal deaths and morbidity and improving child development outcomes.2 Conversely, if investments in maternal and newborn health fail to count stillbirths, their true impact is underestimated.7
Stillbirths are an equity issue. Most occur in low- and middle-income countries (98%), but stillbirth risk is highest for the most marginalised populations in all settings, thus affecting the families across the globe who are most underserved by health systems.4,8
Stillbirths place a heavy burden on families and society, with far-reaching economic, psychosocial, and health consequences for bereaved parents, providers, and communities that are too often overlooked.2,9 When stillbirths are hidden, affected women and families are neglected. Currently, an estimated 4.2 million women are living with depression associated with stillbirth.9
In 2011, The Lancet Stillbirth Series laid out a vision calling for integration of stillbirths into national health plans, health initiatives and global reports; improved data and reporting; actions to reduce stigma and improve bereavement support; and reduced stillbirth rates.10 Given limited action after that series,3 in 2016 The Lancet published the Ending Preventable Stillbirths Series, to re-expose this neglected issue with updated estimates, data on the impact of stillbirth on women and society, and actionable evidence to end preventable stillbirths by 2030.4 Both Series called on governments and partners to appropriately integrate stillbirths within women’s and children’s health initiatives, policies, plans, programmes, and monitoring.2 Yet progress within global and national initiatives has been uneven, as exemplified by the omission of stillbirths from this important BMJ collection.
A national target to end preventable stillbirths was included in The Every Newborn Action Plan and endorsed by 194 countries at the World Health Assembly in 2014, yet only 29 of 90 countries have defined a stillbirth reduction target in their national health plan.11 The stillbirth rate is now a core indicator of the Global Strategy for Women’s, Children’s, and Adolescents’ Health and is included among the WHO's "100 Core Health Indicators"; WHO and UNICEF have committed to producing regular stillbirth rate estimates. Whilst there has been some increase in stillbirth mentions in women’s and children’s health initiatives and related publications,12 silence around stillbirth persists in many relevant policies, funding, and research. This includes this BMJ collection, despite many opportunities to incorporate; for example, adolescence is a risk factor for stillbirths but was not mentioned in Melesse et al.,13 and stillbirth rates strongly reflect global public health inequity but were not mentioned in Barros et al.14
Deliberate action to prevent stillbirths within the continuum of maternal and child healthcare is a necessary step to achieving the SDGs by 2030 and supporting the UN’s commitment to “leaving no one behind”. Taking action now will have a powerful positive impact on the health and life opportunities of millions of women and children for generations to come.
An editorial accompanying this BMJ collection asks: “Is leaving no one behind just rhetoric, or is it leading to measurable change?”15 The exclusion of millions of stillbirths and affected families reflects the very rhetoric itself, by failing to include the full burden of preventable mortality in the global effort to “leave no one behind”.
1. The BMJ. Leaving no woman, no child, and no adolescent behind. 2020. https://www.bmj.com/leaving-no-one-behind. (accessed 03 February).
2. de Bernis L, Kinney MV, Stones W, Ten Hoope-Bender P, Vivio D, Leisher SH, et al. Stillbirths: ending preventable deaths by 2030. Lancet 2016;387(10019):703-16.
3. Froen JF, Friberg IK, Lawn JE, Bhutta ZA, Pattinson RC, Allanson ER, et al. Stillbirths: progress and unfinished business. Lancet 2016;387(10018):574-86.
4. Lawn JE, Blencowe H, Waiswa P, Amouzou A, Mathers C, Hogan D, et al. Stillbirths: rates, risk factors, and acceleration towards 2030. Lancet 2016;387(10018):587-603.
5. World Health Organization. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF. UNFPA, World Bank Group and the United Nations Population Division; 2019.
6. UN Inter-agency Group for Child Mortality Estimation. MOST RECENT CHILD MORTALITY ESTIMATES, 2018. 2019. https://childmortality.org/ (accessed 5 February 2020).
7. Pattinson R, Kerber K, Buchmann E, Friberg IK, Belizan M, Lansky S, et al. Stillbirths: how can health systems deliver for mothers and babies? Lancet 2011;377(9777):1610-23.
8. Flenady V, Wojcieszek AM, Middleton P, Ellwood D, Erwich JJ, Coory M, et al. Stillbirths: recall to action in high-income countries. Lancet 2016;387(10019):691-702.
9. Heazell AE, Siassakos D, Blencowe H, Burden C, Bhutta ZA, Cacciatore J, et al. Stillbirths: economic and psychosocial consequences. Lancet 2016;387(10018):604-16.
10. Goldenberg RL, McClure EM, Bhutta ZA, Belizan JM, Reddy UM, Rubens CE, et al. Stillbirths: the vision for 2020. Lancet 2011.
11. Healthy Newborn Network. Every Newborn Progress Report 2019. Geneva: World Health Organization, 2019.
12. Quigley P. Stillbirth Advocacy Working Group stillbirths series [Internet]. Healthy Newborn Network, editor2019. [cited 5 February 2020]. Available from: https://www.healthynewbornnetwork.org/blog/from-invisibility-to-visibili....
13. Melesse DY, Mutua MK, Choudhury A, Wado YD, Faye CM, Neal S, et al. Adolescent sexual and reproductive health in sub-Saharan Africa: who is left behind? BMJ Global Health 2020;5(1).
14. Barros AJ, Wehrmeister FC, Ferreira LZ, Vidaletti LP, Hosseinpoor AR, Victora CG. Are the poorest poor being left behind? Estimating global inequalities in reproductive, maternal, newborn and child health. BMJ Global Health 2020;5(1).
15. Boerma T, Victora CG, Sabin ML, Simpson PJ. Reaching all women, children, and adolescents with essential health interventions by 2030. British Medical Journal Publishing Group; 2020.
Competing interests: No competing interests