At least 2.6 million fetuses die worldwide after the 28th week of pregnancy every year, a number that has declined only modestly in recent years, researchers said Wednesday.
Fully half of those stillbirths occur during delivery, in large part because women do not receive adequate medical care during the event, according to the first comprehensive study of the problem, reported in six papers and eight commentaries in the journal Lancet.
The number of stillbirths could be reduced by 45% by 2015 in the most affected countries at a cost of only $2.32 per person by such simple expedients as improving obstetric care; treating syphilis infections and hypertension in pregnant women; and identifying and treating medical conditions that block fetal growth, experts said.
The problem is particularly severe in the developing world, with more than three-quarters of the deaths occurring in sub-Saharan Africa and South Asia. But even in high-income countries, it remains a problem, said Dr. Wes Duke of the Centers for Disease Control and Prevention, coauthor of one of the papers.
According to the latest U.S. data, from 2005, almost 26,000 fetuses die each year after the 20th week of gestation, "and that accounts for almost half of all perinatal mortality," Duke said. Stillbirths "continue to be a significant public health burden."
In an introduction to the unprecedented series, Lancet editor in chief Dr. Richard Horton and senior editor Dr. Zoe Mullan wrote: "The grief of a stillborn is unlike any other form of grief: the months of excitement and expectation, planning, eager questions and the drama of labor — all magnifying the devastating incomprehension of giving birth to a baby bearing no signs of life.... Even for a country with a developed health system such as the U.K., [that] means that 11 sets of parents every day will take home their newborn baby in a coffin."
The worldwide numbers are at best an estimate and at worst a wild guess, according to critics, because so many stillbirths in the developing world go unrecorded. The new estimate suggests that the number of deaths after the 28th week of gestation has declined from about 3.03 million in 1995 to 2.64 million in 2009. But if researchers use 22 weeks as a cutoff, as most high-income countries do, the numbers would be about 45% higher.
Overall, rates have been falling by about 1.1% a year, according to the reports, significantly lower than the 2.3% yearly reduction in under-5 mortality and the 2.5% yearly reduction in maternal mortality.
Half of all stillbirths worldwide occur in five countries — India, Pakistan, Nigeria, China and Bangladesh. But China has also been among the most successful in reducing its stillbirth rate, joining Colombia, Mexico and Argentina in bringing down the figure by 40% to 50%.
The U.S., with a rate of 3 stillbirths per 1,000 births, is one of 42 countries with a rate below 5 per 1,000; 37 countries have rates above 25 per 1,000. The rate for stillbirths among African American women in the U.S. is nearly three times that for white women, Duke said, and while socioeconomic inequalities certainly play a role, the overall reasons for the disparity are not known.
The National Institutes of Health is in the process of conducting a major study to examine the causes, and the results should be available soon, he added.
Around the world, causes of stillbirths include umbilical cord problems (9%), infections (12%), congenital abnormalities (6%), birth complications (3%), direct fetal causes such as blood disorders and incompatibilities (4%) and maternal problems such as obesity and hypertension (7%). But the causes of the rest remain unknown, even in high-income countries.
Poor obstetric care is thought to be a contributing factor in about 6 of every 10 cases.
In a commentary, Janet Scott of the Stillbirth and Neonatal Death charity in London, who has experienced a stillbirth herself, wrote: "Stillbirth is one of the last taboos — the death of a baby before birth somehow considered not to count. The failure to prevent stillbirth suggests an almost public acceptance that it is just 'one of those things….' But if we undervalue the damage that follows a stillbirth, we leave bereaved families to grieve in isolation and silence, and the problem remains ignored."