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. 2024 Nov 16;404(10466):1955-1988.
doi: 10.1016/S0140-6736(24)01925-1. Epub 2024 Nov 4.

Global, regional, and national stillbirths at 20 weeks' gestation or longer in 204 countries and territories, 1990-2021: findings from the Global Burden of Disease Study 2021

GBD 2021 Global Stillbirths Collaborators
Collaborators

Global, regional, and national stillbirths at 20 weeks' gestation or longer in 204 countries and territories, 1990-2021: findings from the Global Burden of Disease Study 2021

GBD 2021 Global Stillbirths Collaborators. Lancet. .

Abstract

Background: Stillbirth is a devastating and often avoidable adverse pregnancy outcome. Monitoring stillbirth levels and trends-in a comprehensive manner that leaves no one uncounted-is imperative for continuing progress in pregnancy loss reduction. This analysis, completed as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, methodically accounted for different stillbirth definitions with the aim of comprehensively estimating all stillbirths at 20 weeks or longer for 204 countries and territories from 1990 to 2021.

Methods: We extracted data on stillbirths from 11 412 sources across 185 of 204 countries and territories, including 234 surveys, 231 published studies, 1633 vital statistics reports, and 10 585 unique location-year combinations from vital registration systems. Our final dataset comprised 11 different definitions, which were adjusted to match two gestational age thresholds: 20 weeks or longer (reference) and 28 weeks or longer (for comparisons). We modelled the ratio of stillbirth rate to neonatal mortality rate with spatiotemporal Gaussian process regression for each location and year, and then used final GBD 2021 assessments of fertility and all-cause neonatal mortality to calculate total stillbirths. Secondary analyses evaluated the number of stillbirths missed with the more restrictive gestational age definition, trends in stillbirths as a function of Socio-demographic Index, and progress in reducing stillbirths relative to neonatal deaths.

Findings: In 2021, the global stillbirth rate was 23·0 (95% uncertainty interval [UI] 19·7-27·2) per 1000 births (stillbirths plus livebirths) at 20 weeks' gestation or longer, compared to 16·1 (13·9-19·0) per 1000 births at 28 weeks' gestation or longer. The global neonatal mortality rate in 2021 was 17·1 (14·8-19·9) per 1000 livebirths, corresponding to 2·19 million (1·90-2·55) neonatal deaths. The estimated number of stillbirths occurring at 20 weeks' gestation or longer decreased from 5·08 million (95% UI 4·07-6·35) in 1990 to 3·04 million (2·61-3·62) in 2021, corresponding to a 39·8% (31·8-48·0) reduction, which lagged behind a global improvement in neonatal deaths of 45·6% (36·3-53·1) for the same period (down from 4·03 million [3·86-4·22] neonatal deaths in 1990). Stillbirths in south Asia and sub-Saharan Africa comprised 77·4% (2·35 million of 3·04 million) of the global total, an increase from 60·3% (3·07 million of 5·08 million) in 1990. In 2021, 0·926 million (0·792-1·10) stillbirths, corresponding to 30·5% of the global total (3·04 million), occurred between 20 weeks' gestation and 28 weeks' gestation, with substantial variation at the country level.

Interpretation: Despite the gradual global decline in stillbirths between 1990 and 2021, the overall number of stillbirths remains substantially high. Counting all stillbirths is paramount to progress, as nearly a third-close to 1 million in total-are left uncounted at the 28 weeks or longer threshold. Our findings draw attention to the differential progress in reducing stillbirths, with a high burden concentrated in countries with low development status. Scarce data availability and poor data quality constrain our capacity to precisely account for stillbirths in many locations. Addressing inequities in universal maternal health coverage, strengthening the quality of maternal health care, and improving the robustness of data systems are urgently needed to reduce the global burden of stillbirths.

Funding: Bill & Melinda Gates Foundation.

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Conflict of interest statement

Declaration of interests S Afzal reports support for the present manuscript from King Edward Medical University, which provided study material, research articles, valid data sources, and authentic real-time information for this manuscript; reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from King Edward Medical University and collaborative partners including University of Johns Hopkins, University of California, University of Massachusetts, King Edward Medical College Alumni Association of North America (KEMCAANA), and Kings Edward Medical College Alumni Association UK (KEMCA-UK), as well as participation in international scientific conferences, webinars, and meetings; support for attending meetings or travel, or both, from King Edward Medical University to discuss findings and gather the latest information from various sources; participation on a Data Safety Monitoring Board or Advisory Board with the National Bioethics Committee Pakistan, the King Edward Medical University Ethical Review Board, the Ethical Review Board Fatima Jinnah Medical University and Sir Ganga Ram Hospital, and the Technical Working Group on Infectious Diseases to formulate guidelines; leadership or fiduciary roles in board, society, committee, or advocacy groups paid or unpaid with the Pakistan Association of Medical Editors, the Society of Prevention, Advocacy, and Research at King Edward Medical University (SPARK), and the Pakistan Society of Infectious Diseases, as well as being a Fellow of the Faculty of Public Health Royal Colleges UK (FFPH); other support from serving as Dean of Public Health and Preventive Medicine and Chief Editor of the Annals of King Edward Medical University since 2014, Director of the Quality Enhancement Cell at King Edward Medical University, Advisory Board Member and Chair of the Scientific Session at KEMCA-UK, and Chairperson of the International Scientific Conference at KEMCAANA; other support from membership in the Research and Publications Committee of the Higher Education Commission (HEC) Pakistan, the Research and Journals Committee at the Pakistan Medical and Dental Council, and the National Bioethics Committee Pakistan; other support from serving on the Corona Experts Advisory Group, the Technical Working Group on Infectious Diseases, the Dengue Experts Advisory Group, and as Chair of the Punjab Residency Program Research Committee; all outside the submitted work. R Bai reports support for the present manuscript from the Social Science Fund of Jiangsu Province (grant number 21GLD008) and the Fundamental Research Funds for the Central Universities (grant number 30923011101). S Bhaskar reports grants or contracts from the Japan Society for the Promotion of Science (JSPS), Japanese Ministry of Education, Culture, Sports, Science and Technology (MEXT), including Grant-in-Aid for Scientific Research (KAKENHI) (P23712), and the JSPS and the Australian Academy of Science JSPS International Fellowship (P23712); leadership or fiduciary roles in board, society, committee, or advocacy groups paid or unpaid with Rotary District 9675, Sydney, Australia (District Chair, Diversity, Equity & Inclusion), Global Health & Migration Hub Community, Global Health Hub Germany, Berlin, Germany (Chair, Founding Member, and Manager), PLOS One, BMC Neurology, Frontiers in Neurology, Frontiers in Stroke, Frontiers in Public Health, Journal of Aging Research, and BMC Medical Research Methodology (Editorial Board Member), College of Reviewers, Canadian Institutes of Health Research (CIHR), Government of Canada (Member), World Headache Society, Bengaluru, India (Director of Research), Cariplo Foundation, Milan, Italy (Expert Adviser/Reviewer), National Cerebral and Cardiovascular Center, Department of Neurology, Suita, Osaka, Japan (Visiting Director), and Cardiff University Biobank, Cardiff, UK (Member, Scientific Review Committee); all outside the submitted work. A A Fomenkov reports support for the present manuscript from research carried out within the state assignment of the Ministry of Science and Higher Education of the Russian Federation (theme number 122042600086-7). A Guha reports grants or contracts from the American Heart Association and the US Department of Defense; consulting fees from Pfizer and Novartis; and leadership or fiduciary roles in board, society, committee, or advocacy groups paid or unpaid with ZERO Prostate Cancer Health Equity Task Force; all outside the submitted work. C Herteliu reports grants or contracts from the Romanian Ministry of Research, Innovation and Digitalization through UEFISCDI for the project “Analysis of the impact of Covid-19 on the main demographic indicators in Romania and the Republic of Moldova by using econometric modeling” (code PN-IV-P8-8.3-ROMD-2023-0208); a grant from the European Commission Horizon 4P-CAN (Personalised Cancer Primary Prevention Research through Citizen Participation and Digitally Enabled Social Innovation); the European Union – NextGenerationEU and Romanian Government under the National Recovery and Resilience Plan for Romania for the projects “Societal and Economic Resilience within multi-hazards environment in Romania” (contract number 760050/23.05.2023, cod PNRR-C9-I8-CF 267/29.11.2022) and “A better understanding of socio-economic systems using quantitative methods from Physics” (contract number 760034/23.05.2023, cod PNRR-C9-I8-CF 255/29.11.2022) within Component 9, Investment I8; all outside the submitted work. I M Ilic reports support for the present manuscript from the Ministry of Education, Science and Technological Development, Republic of Serbia, project number 175042, 2011–2023. M D Ilic reports support for the present manuscript from the Ministry of Science, Technological Development and Innovation of the Republic of Serbia (number 451-03-47/2023-01/200111). B Lacey reports support for the present manuscript from UK Biobank, funded largely by the UK Medical Research Council and Wellcome; and reports employment with the University of Oxford, with the post funded by a grant from UK Biobank; all outside the submitted work. M Lee reports support for the present manuscript from the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea (NRF-2023S1A3A2A05095298). M-C Li reports support for the present manuscript from the National Science and Technology Council, Taiwan (NSTC 113-2314-B-003-002); and reports leadership or fiduciary roles in other board, society, committee, or advocacy groups, paid or unpaid with the Journal of the American Heart Association as Technical Editor; all outside the submitted work. L Monasta reports support for the present manuscript from the Italian Ministry of Health (Ricerca Corrente 34/2017), with payments made to the Institute for Maternal and Child Health IRCCS Burlo Garofolo. F Mughal reports support for the present manuscript from NIHR Doctoral Fellow, 300957, with payments made to Keele University. S Nomura reports support for the present manuscript from the Ministry of Education, Culture, Sports, Science and Technology of Japan (24H00663) and the Precursory Research for Embryonic Science and Technology from the Japan Science and Technology Agency (JPMJPR22R8). A P Okekunle reports support for the present manuscript from the National Research Foundation of Korea funded by the Ministry of Science and ICT (2020H1D3A1A04081265); and reports support for attending meetings or travel, or both, from the National Research Foundation of Korea funded by the Ministry of Science and ICT (2020H1D3A1A04081265); all outside the submitted work. M Pigeolet reports grants or contracts from the Belgian Kids' Fund for Pediatric Research. L Ronfani reports support for the present manuscript from the Italian Ministry of Health (Ricerca Corrente 34/2017), with payments made to the Institute for Maternal and Child Health IRCCS Burlo Garofolo. J P Silva reports support for the present manuscript from the Portuguese Foundation for Science and Technology, with payment of salary under the contract reference 2021.01789.CEECIND/CP1662/CT0014. C R Simpson reports grants or contracts from the Health Research Council (HRC) of New Zealand, the New Zealand Ministry of Health, the Ministry of Business, Innovation and Employment (MBIE) of New Zealand, the Chief Scientist Office of the UK, and the UK Medical Research Council; and leadership or fiduciary roles in board, society, committee, or advocacy groups, paid or unpaid with the New Zealand Government Data Ethics Advisory Group (Chair, remunerated under the NZ Cabinet Fees Framework); all outside the submitted work. J A Singh reports consulting fees from ROMTech, Atheneum, Clearview Healthcare Partners, American College of Rheumatology, Yale, Hulio, Horizon Pharmaceuticals, DINORA, ANI/Exeltis USA, Frictionless Solutions, Schipher, Crealta/Horizon, Medisys, Fidia, PK Med, Two Labs, Adept Field Solutions, Clinical Care Options, Putnam Associates, Focus Forward, Navigant Consulting, Spherix, MedIQ, Jupiter Life Science, UBM LLC, Trio Health, Medscape, WebMD, Practice Point Communications, and the US National Institutes of Health, with consultant fees paid directly for each entity; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from the speakers bureau of Simply Speaking; support for attending meetings or travel, or both, from OMERACT, as a past steering committee member and received support to attend meetings every 2 years; participation on a Data Safety Monitoring Board or Advisory Board with the FDA Arthritis Advisory Committee, as a member without financial support; leadership or fiduciary roles in board, society, committee, or advocacy groups paid or unpaid with OMERACT (an international organisation developing clinical trial measures funded at arm's length by pharmaceutical companies, with J A Singh previously receiving meeting support), as Chair of the Veterans Affairs Rheumatology Field Advisory Committee (without financial support), and as Editor and Director of the UAB Cochrane Musculoskeletal Group Satellite Center on Network Meta-analysis (without financial support); and stock or stock options in Atai Life Sciences, Kintara Therapeutics, Intelligent Biosolutions, Acumen Pharmaceutical, TPT Global Tech, Vaxart Pharmaceuticals, Atyu Biopharma, Adaptimmune Therapeutics, GeoVax Labs, Pieris Pharmaceuticals, Enzolytics, Seres Therapeutics, Tonix Pharmaceuticals Holding Corp., Aebona Pharmaceuticals, and Charlotte's Web Holdings, with previous stock ownership in Amarin, Viking, and Moderna Pharmaceuticals; all outside the submitted work. S J Tromans reports grants or contracts from NHS Digital via the Department of Health and Social Care for the 2023 Adult Psychiatric Morbidity Survey, with payments made to the University of Leicester; and reports leadership or fiduciary roles in board, society, committee, or advocacy groups paid or unpaid with the Neurodevelopmental Psychiatry Special Interest Group, the Faculty of Psychiatry of Intellectual Disability (both Royal College of Psychiatrists), and editorial board roles with BMC Psychiatry, Advances in Mental Health and Intellectual Disabilities, Advances in Autism, and Progress in Neurology and Psychiatry; all outside the submitted work. G Zamagni reports support for the present manuscript from the Italian Ministry of Health (Ricerca Corrente 34/2017), with payments made to the Institute for Maternal and Child Health IRCCS Burlo Garofolo. M Zielińska reports other financial or non-financial interests as an employee of AstraZeneca; all outside the submitted work. All other authors declare no competing interests.

Figures

Figure 1
Figure 1
Global trends in the number of stillbirths, SBR, SBR to NMR ratio, and annualised rate of change in SBR, 1990–2021 (A) The solid line represents estimates for the total number of stillbirths (in millions) for the 20 weeks or longer definition, and the shaded area indicates the 95% UI, between 1990 and 2021. (B) The solid line represents the SBR estimates per 1000 births for the 20 weeks or longer definition, and the shaded area indicates the 95% UI, between 1990 and 2021. (C) The solid line represents the SBR to NMR ratio estimates (neonatal deaths per 1000 livebirths) for the 20 weeks or longer definition, and the shaded area indicates the 95% UI, between 1990 and 2021. (D) The solid line represents the annualised rate of change in SBR between adjacent years for the 20 weeks or longer definition, and the shaded area indicates the 95% UI, between 1990 and 2021. NMR=neonatal mortality rate. SBR=stillbirth rate (stillbirths at ≥20 weeks' gestation per 1000 births). UI=uncertainty interval.
Figure 2
Figure 2
Maps of SBR, percentage change in SBR between 2015 and 2021, and percentage of stillbirths between 20 weeks' and less than 28 weeks' gestation in 2021 (A) The map shows SBR (per 1000 births) in 2021 for the 20 weeks or longer stillbirth definition. The colour scale diverges at an SBR of 12 to indicate whether countries met the ENAP target of 12 or fewer stillbirths per 1000 births in 2021. (B) The map shows the percentage change in SBR since the ENAP target was published, from 2015 to 2021. The colour scale diverges on the basis of whether SBR increased (purple) or decreased (green), with darker colours indicating a larger change in the respective direction. (C) The map shows the percentage of stillbirths that occurred between 20 weeks' and less than 28 weeks' gestation in 2021. Countries with a larger percentage of stillbirths between 20 weeks' and less than 28 weeks' gestation are darker in colour. ENAP=Every Newborn Action Plan. SBR=stillbirth rate (stillbirths at ≥20 weeks' gestation per 1000 births).
Figure 3
Figure 3
Comparative improvement in SBR and NMR and the historical association between SBR and SDI from 2000 to 2021 (A) Data points compare the percentage change in SBR and the percentage change in NMR for the 20 weeks or longer definition between 2000 and 2021 by GBD super-region, indicated by colour. Between 2000 and 2021, points in the bottom left quadrant had decreases in both SBR and NMR; points in the top left quadrant had a decrease in SBR but an increase in NMR; points in the top right quadrant had increases in both SBR and NMR; and points in the bottom right quadrant had an increase in SBR but a decrease in NMR. The diagonal line depicts where the change in SBR and NMR between 2000 and 2021 was equal. All data points not in the bottom left quadrant are labelled. (B) The scatter plot shows the spline fit between SBR and SDI, where each point represents a location. Point shape indicates year, and colour indicates GBD super-region. GBD=Global Burden of Diseases, Injuries, and Risk Factors Study. NMR=neonatal mortality rate (neonatal deaths per 1000 livebirths). SBR=stillbirth rate (stillbirths at ≥20 weeks' gestation per 1000 births). SDI=Socio-demographic Index. *Locations that had statistically significant increases in SBR.
Figure 4
Figure 4
Country-specific relative changes in SBR and NMR between 2000 and 2021, ratio of observed to expected SBR based on SDI in 2021, and distribution of countries based on stillbirth performance (A) The map shows the ratio of absolute change in SBR over absolute change in NMR between 2000 and 2021. The colour scale diverges at a ratio of 1 based on whether the change in NMR was larger (purple) or change in SBR was larger (green), with darker colours indicating greater disparity in the change. (B) The map shows the ratio of the observed SBR for the 20 weeks or longer definition in 2021 compared to what SBR would be expected according to SDI, by country. The colour scale diverges at an observed to expected ratio of 1 according to whether SBR is smaller than expected (green) or larger than expected (purple). (C) The table depicts the number of countries in 25 scenarios based on their observed to expected ratio of SBR and the change in NMR to SBR ratio. The green boxes indicate countries where SBR improvements are greater than those in NMR and SDI, yellow boxes indicate where all three are similar, and red boxes indicate where SBR is not keeping up with NMR and SDI. NMR=neonatal mortality rate (neonatal deaths per 1000 livebirths). SBR=stillbirth rate (stillbirths ≥20 weeks' gestation per 1000 births). SDI=Socio-demographic Index.
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References

    1. Shetty AK. Global maternal, newborn, and child health. Pediatr Clin North Am. 2016;63:1–18. - PubMed
    1. Crockett M, Avery L, Blanchard J. Program science—a framework for improving global maternal, newborn, and child health. JAMA Pediatr. 2015;169:305–306. - PubMed
    1. WHO Millennium Development Goals (MDGs) Feb 19, 2018. https://www.who.int/news-room/fact-sheets/detail/millennium-development-...
    1. UN Department of Economic and Social Affairs The 17 goals. https://sdgs.un.org/goals
    1. Lawn JE, Gravett MG, Nunes TM, Rubens CE, Stanton C. Global report on preterm birth and stillbirth (1 of 7): definitions, description of the burden and opportunities to improve data. BMC Pregnancy Childbirth. 2010;10(suppl 1):S1. - PMC - PubMed

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