Ending preventable stillbirths and improving bereavement care: a scorecard for high- and upper-middle income countries

Abstract

Background: Despite progress, stillbirth rates in many high- and upper-middle income countries remain high, and the majority of these deaths are preventable. We introduce the Ending Preventable Stillbirths (EPS) Scorecard for High- and Upper Middle-Income Countries, a tool to track progress against the Lancet's 2016 EPS Series Call to Action, fostering transparency, consistency and accountability.

Methods: The Scorecard for EPS in High- and Upper-Middle Income Countries was adapted from the Scorecard for EPS in Low-Income Countries, which includes 20 indicators to track progress against the eight Call to Action targets. The Scorecard for High- and Upper-Middle Income Countries includes 23 indicators tracking progress against these same Call to Action targets. For this inaugural version of the Scorecard, 13 high- and upper-middle income countries supplied data. Data were collated and compared between and within countries.

Results: Data were complete for 15 of 23 indicators (65%). Five key issues were identified: (1) there is wide variation in stillbirth rates and related perinatal outcomes, (2) definitions of stillbirth and related perinatal outcomes vary widely across countries, (3) data on key risk factors for stillbirth are often missing and equity is not consistently tracked, (4) most countries lack guidelines and targets for critical areas for stillbirth prevention and care after stillbirth and have not set a national stillbirth rate target, and (5) most countries do not have mechanisms in place for reduction of stigma or guidelines around bereavement care.

Conclusions: This inaugural version of the Scorecard for High- and Upper-Middle Income Countries highlights important gaps in performance indicators for stillbirth both between and within countries. The Scorecard provides a basis for future assessment of progress and can be used to help hold individual countries accountable, especially for reducing stillbirth inequities in disadvantaged groups.

Keywords: Accountability; Bereavement; Data; Equity; High-income countries; High-resource setting; Performance indicators; Scorecard; Stigma; Stillbirth.

Fig. 1

Perinatal-related mortality rates using national definitions, against a 28 + weeks stillbirth rate benchmark. Notes to figure: See Additional file 3 for country-specific definitions. ^a Stillbirth rates are for 25 + weeks gestation (data missing for 28 + weeks). ^b Data from Spain and Italy may be inaccurate due to data quality issues, such as missing data and underreporting. In the case of the Spanish 2019 dataset (National Institute of Statistics, fetal deaths), gestational age data was missing for 12% of cases. Based on a previously conducted analysis of the 2015 dataset, 84% of cases with missing data on gestational age were replaced with a gestational age ≥ 28 weeks. Abbreviations: ENND, early neonatal death; LNND, late neonatal death; SBR, stillbirth rate

Fig. 2

Scatterplot: GDP per capita in $US (2020) and Gini Index by 28 + weeks stillbirth rate. Notes to figure: Sources: GDP per capita in US$: World Bank [21]; Gini Index (a measure of income equality): World Bank [22]; except for New Zealand (worldpopulationreview.com) [23]. As an outlier, Brazil was not presented in this figure (SBR 28 + weeks = 7.0; GDP = 6789; Gini = 53.4). ^a Italy stillbirth rates are for 25 + weeks gestation (data missing for 28 + week). ^b In Luxembourg, where a significant proportion of GDP refers to repatriated profits and thus is not available for national consumption, Gross National Income may be a more meaningful measure than GDP. However, for consistency, GDP was used as the denominator for all countries. Abbreviations: GDP, Gross Domestic Product; SBR, Stillbirth Rate

Fig. 3

Percentage of the 11 quality targets reported as ‘present’ for 13 countries globally. Notes to figure: Quality indicators are 4.1 to 4.11 in Additional file 2. Quality indicators with missing data counted as ‘absent’ in total % calculations. Australia = 91%; Austria = 18%; Brazil = 27%; Croatia = 46%; Finland = 36%; Ireland = 73%; Italy = 36%; Luxembourg = 55%; the Netherlands = 64%; New Zealand = 64%; Spain = 36%; United Kingdom (UK) = 73%; United States of America (USA) = 27%

Fig. 4

Percentage of the 11 quality targets reported as ‘present’ for eight European countries. Notes to figure: Quality indicators are 4.1 to 4.11 in Additional file 2. Quality indicators with missing data counted as ‘absent’ in total % calculations. Austria = 18%; Croatia = 46%; Finland = 36%; Ireland = 73%; Italy = 36%; Luxembourg = 55%; the Netherlands = 64%; Spain = 36%; United Kingdom (UK) = 73%