Media Release

New Research Published in The Lancet Reveals
23,000 Babies Are Stillborn Every Year in South Africa

The global report highlights 2.6 million stillbirths per year. South Africa’s ranks 176 out of 193 countries for stillbirth numbers and 148 for stillbirth rate. Improving quality of care at birth and targeting disparities are key priorities for action.

Globally more than 2.6 million women experience stillbirth in the last 12 weeks of pregnancy every year, according to the first comprehensive set of stillbirth estimates, published in a special issue of The Lancet medical journal. The special series drew on the efforts of 69 authors from more than 50 organizations and 18 countries, with two papers being lead by South African authors.

Every day more than 7,300 babies are stillborn globally. In South Africa over 61 babies are stillborn each day. A death occurs just when parents expect to welcome a new life. These stillbirths are in addition to 58 newborn deaths every day, and yet newborn, child and maternal deaths count in national and global goals, but stillbirths do not.

“Almost no burden affecting families is so big and yet so invisible in society and on the global public health agenda. Yet this invisible loss deeply affects women all over the world. The new information documents their hidden grief as well as the social stigma these women often endure,” said Joy Lawn, Director of Global Evidence and Policy for Save the Children’s Saving Newborn Lives programme from Cape Town, coordinator of the new stillbirth estimates and a lead author of The Lancet’s Stillbirths Series. These are the first ever official estimates of stillbirth done in partnership with the World Health Organisation.

Globally, stillbirths have declined by only 1.1 percent per year, from 3 million per year in 1995 to 2.6 million in 2009.  This is slower than reductions for child and maternal mortality. In South Africa, the average rate of decline has only been 0.9 percent per year, from an estimated 25,000 stillbirths in 1995 to 23,000 stillbirths in 2009.

The new stillbirth estimates would be even higher than 2.6 million under broader definitions used in most high-income countries.  The Lancet authors used the WHO international definition, which classifies stillbirth as the loss of pregnancy after the 28th week.  South Africa has a rate of 20 stillbirths per 1,000 births in 2009 using the WHO definition.

The new findings in The Lancet’s Stillbirths Series include:

• 98 percent of stillbirths occur in low- and middle-income countries
• Half of all stillbirths occur in just 5 countries - India, Pakistan, Nigeria, China and Bangladesh. 
• Pakistan has the highest rate of stillbirths – nearly 47 per 1,000 births.
• Two-thirds of stillbirths occur in rural areas, where trained and skilled midwives are scarce.
• Worldwide, the rate of stillbirths has dropped by only 1.1 percent each year since 1995 – much slower progress than for maternal and child deaths.
• Finland and Singapore have the lowest stillbirth rate – 2 stillbirths per 1,000 births.
• In high-income countries, the rate of decline in stillbirths has stagnated and 1 in 320 pregnancies end in stillbirth.

The Lancet special series highlightsthe “big five” causes of stillbirths: childbirth complications, maternal infections in pregnancy, maternal disorders, fetal growth restriction and congenital abnormalities. Almost half of all stillbirths (1.2 million a year) occur during labor and delivery. More research is needed on the interaction between HIV and pregnancy.

Interventions such as emergency obstetric care and treatment of maternal infections and conditions could prevent 44% of stillbirths (1.1 million worldwide) if made universally available (99%) in countries with the highest burden of stillbirths, according to the new analysis in The Lancet.  In total 2.7 million deaths of mothers and newborns and stillbirths could be prevented, at only an additional cost of US$2.32 per person.

In South Africa universal coverage of key interventions for maternal and newborn health and stillbirths could prevent 24,000 deaths at an additional cost of ZAR 35 per person.

Prof Robert Pattinson, Director of the Medical Research Council and University of Pretoria Maternity and Infant Strategies Research Unit, states that ‘Maternal and newborn deaths as well as stillbirths could be prevented by improving quality of care, especially during child birth, addressing overcrowding and understaffing in facilities as well as developing the skills and commitment of those working in the health care system.”

The Lancet‘s Stillbirths Series includes groundbreaking analysis of this invisible and undercounted tragedy affecting women and families around the world. “Now that we have reliable data on stillbirths and consensus on how to prevent them, we must act. The positive news is that the same basic services proven to reduce maternal and newborn deaths could prevent over a million stillbirths worldwide each year. It is now clearer than ever that these services - especially care at birth - have a triple return on investment. Counting the stillbirths is added value for families and for health programs,” said Lawn.

The Lancet series is being launched globally this week. As of April 15, 2011, papers available free at:  www.lancet.com/series/stillbirth
TV coverage and clips at www.lancet.com

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For more information contact:

Julian Jacobs on 082 454 4902

Note to the Editor:

South Africa report card

*out of 193 countries

Overview of the papers

Paper One: Stillbirths: Why They Matter
Stillbirth prevention is closely linked with prevention of maternal and neonatal deaths.  In an era of global efforts in maternal health, most mothers’ own aspiration – a live baby – has been absent from the global health agenda.  Affected mothers are often subjected to harsh stigma and marginalisation in communities that blame her stillbirth on her own sins, evil spirits and destiny.  Most stillborn babies around the globe are disposed of without any recognition such as being named, held or dressed or a funeral, and are often seen as taboo objects.  Fatalism is widespread, and to prioritise stillbirth prevention, health professionals need data on rates, causes and preventive opportunities, as well as global leadership.

Paper Two:  Stillbirths: Where? When? Why? How to make the data count?
This paper presents new epidemiological data to prioritise actions to reduce stillbirth.  Prior to 2006, no global estimates on stillbirth had been published.  When countries are categorised by their stillbirth rate, there are clear correlations with maternal and neonatal mortality, as well as health system indicators.  The paper highlights the variations in stillbirth rates regionally, nationally, and sub-nationally, the importance of maternal conditions for stillbirths and neonatal deaths  as well as the importance of improving national stillbirth data to inform action.  There is now more than enough data to justify urgent attention and action to reduce this large burden of around 3 million stillbirths in the last 12 weeks of pregnancy, linked to around 3 million early neonatal deaths and 350 000 maternal deaths.  Stillbirths remain invisible on programmatic and policy priorities and yet are highly relevant to current investigations for maternal and neonatal health, especially for care at the time of birth when a combined 2 million deaths occur. 

Paper Three:  What Works? How much difference can we make and at what cost?
A model using Lives Saved Tool (LiST) evaluating the potential impact of feasible intervention packages across 68 countdown priority countries with varying stillbirth burdens, indicates that if implemented at scale, these have the potential of averting a substantial proportion of stillbirths.  While basic and comprehensive emergency obstetric care had the maximum impact on reducing stillbirths, other interventions, especially those with the potential of inclusion in expanded antenatal care packages also have considerable potential of reducing stillbirth. Similarly screening, preventing and managing infections such as malaria and syphilis in endemic areas through effective outreach services also offer the potential of significant gains in low income countries. The overall costs for these interventions are within the general estimates of cost effective interventions for maternal care especially given the impact on outcomes across the spectrum of maternal, fetal and newborn health.

Paper Four:  Stillbirths: How can health systems deliver for mothers and babies?
Causes of stillbirths, and the solutions are frequently the same for maternal and neonatal deaths and the time of birth is critical especially in low and middle income countries and the solutions overlap.  Interventions are best packaged and provided through linked service delivery modes tailored to suit existing health care systems. Services should be integrated providing a continuum of care not only from home to hospital but also from pre-pregnancy to postnatal care.  If achieving universal coverage (99%) coverage of care with these packages is reached in 2015, a substantial proportion of maternal and newborn deaths and stillbirths in the 68 priority countries could be saved with additional cost which is comparable with other global price tags.  A health care system is a complex adaptive system, so to successfully implement and sustain programmes requires interventions at the key interfaces.  Coverage is improved if the woman has basic information and accessibility to services, quality of care is improved if health care providers have skills, knowledge and resources to provide care. Each aspect needs specific (targeted) implementation strategies which are designed to meet the needs of the population served.

Paper Five: Stillbirth: The way forward in high income countries 
While further research is needed, this paper highlights that many stillbirths in HIC are potentially preventable. The disparity associated with disadvantaged populations requires urgent attention through improving 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 lack of quality data on stillbirths is a major impediment to stillbirth prevention. Improvements in investigation and reporting practices, including consensus of definition and classification systems is urgently needed. Implementation of perinatal mortality audit at a national level could result in important reductions in stillbirth in HIC through improving quality of data and standards of maternity care. Parents have the greatest stake of all in the wellbeing of their baby, and must be part of the drive to reduce stillbirth. Parents and health professional working collaboratively (in such models as the International Stillbirth Alliance) have a powerful role to play in bringing stillbirth to public attention and pushing for the prioritisation of stillbirth in research and maternity services.

Paper Six: Stillbirth: The vision for 2020
The overall goal to achieve by 2020 is for all countries to reduce the stillbirth rate to < 5 per 1000 births, and in high-income countries, to eliminate all preventable stillbirths.  Achieving a substantial reduction in stillbirths worldwide will require concerted action by many participants including country, regional and local governments, and their official health departments, the WHO and other international organisations, foundations and research institutes which must be guided by a series of goals recommended in this paper.  We encourage all those with a specific interest in stillbirths, including the research community, to engage with those interested in improving other pregnancy outcomes so that an evidence based united front for improving all pregnancy outcomes is created. 

The entire series of article can be viewed on: http://www.thelancet.com/series/stillbirth

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