Stillbirth: moving from advocacy to action.

Abstract

The incidence of stillbirth in high-income countries has progressively declined over the past 50 years, but has plateaued in many (Lawn et al., Lancet 2016;387:587–603). Stillbirth continues to be a vexing problem, often relegated to the shadows out of a sense of guilt and shame among patients, their families, and obstetric providers. For far too long, efforts to address stillbirth have been meager. The recent Lancet series on stillbirth, along with the BJOG themed issue on stillbirth, bring into stark relief the extent of the problem of stillbirth worldwide. Such efforts have led to meaningful reductions in stillbirth, even in some high-income countries. In this commentary from the Stillbirth Advocacy Working Group (Ateva et al. BJOG 2018;1058–60), the authors bring into sharp focus the need for increased research on stillbirth, with an emphasis on awareness, bereavement, voice, and leadership. Key to this effort will be a uniform definition of stillbirth. The wide variety of definitions makes comparing data difficult, and the lack of a common language only further hampers progress. Adopting a common set of definitions and outcomes, as advocated through the CROWN initiative (Khan et al. BJOG 2016;123(S3):103–4), would be a major step in addressing this problem. Additionally, the authors highlight that the majority of stillbirths occur in low- and middle-income countries, but even high-income countries with low rates can improve. We applaud the authors and wholeheartedly endorse all of their points and goals. In order to truly reduce the rate of stillbirths we must marshal advocates, political will, and considerable resources; however, in addition to the ‘10 000-foot view’ put forth in this commentary, and in prior worldwide programmes, focusing on clinical and public health research efforts on specific interventions to prevent stillbirth is crucial. Such efforts should emphasise precise policies, algorithms, and bundles targeting conditions known to cause or contribute to stillbirth. The opportunity is greatest in low-resource settings with relatively high stillbirth rates. Many stillbirths can be prevented using current knowledge through improved access to better prenatal and intrapartum care and safe cesarean delivery. Of course, a lack of resources in settings with many other priorities remains a barrier. Research efforts are more complex in high-income countries that enjoy relatively lower rates of stillbirth and have already implemented many evidence-based strategies. Accordingly, it makes sense to focus on the subset of conditions with the best opportunities for prevention. A recent US study identified 25% of such cases (Page et al. Obstet Gynecol 2018;131:336–43). Future efforts should concentrate on more precise methods to screen for stillbirth risk and on specific strategies to prevent them. Continued advocacy efforts such as those promoted by the Stillbirth Advocacy Working Group will help to lift the veil from stillbirth; however, until there is political will from governments and funding agencies with a focused effort to fund interventional trials aimed at preventing stillbirth, far too many families will continue to suffer this scourge. Now is the time to bring stillbirth out of the shadows and into the light, and make real progress in addressing this tragedy. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.