Stillbirths as a public health issue

Each year childbirth complications result in one million babies being born dead, and almost one million more dying in the first few days of life

New global estimates published in the June issue of the Bulletin of the World Health Organization suggest that each year 904 400 newborn babies die in the first few days of life as a consequence of complications in childbirth and a further 1.02 million babies die during labor.

These are the first published global estimates for deaths of babies during labor (intrapartum stillbirths). The newborn deaths estimates from this study are the first using a more specific definition. The term "birth asphyxia" previously included other causes of newborn death such as complications of prematurity. These new estimates are the most rigorous to date. Dr. Joy Lawn from Saving Newborn Lives/Save the Children-USA (an initiative funded by the Bill and Melinda Gates Foundation since 2000) worked with Dr. Kenji Shibuya and Dr. Claudia Stein of the World Health Organization to develop new methods using the limited data available from vital registration and research studies.

Intrapartum stillbirths are the single largest group of stillbirths, at 27 percent of the global total. Women in Africa are at least 16 times more likely to experience an intrapartum stillbirth than women in Western Europe. Newborn deaths due to birth asphyxia account for 8 percent of all deaths among children under five years of age, making this the fifth most common cause of death in children, after pneumonia, diarrhea, neonatal infections, and preterm birth. Yet very little attention or funding are directed towards tackling birth asphyxia and it is rarely mentioned in lists of the causes of child death.

The World Health Report highlights long-term disability for babies who survive birth asphyxia as an important but silent problem. The Report also urges a new approach to maternal, newborn and child health that provides a continuum of care and does not see them as three separate issues.

"Given the numbers of deaths revealed here it is clear that complications during childbirth are a major cause of newborn deaths and of stillbirths --- yet are neglected in policy and programs and need systematic attention." said Dr. Lawn.

Solutions to save these babies exist, particularly skilled care and newborn resuscitation but these are not reaching the women and babies who need them most.

In rich countries, 99 percent of women deliver with a skilled attendant. In contrast, only about one-third of the women in the sub-Saharan Africa and South Asia deliver with a skilled attendant, and far fewer have access to emergency obstetric care. Of the approximately 5 million babies who require resuscitation each year, less than 5 percent have an attendant who is able and equipped to carry out resuscitation.

"If more resources were invested into care during childbirth, and to ensure that midwives are equipped to perform newborn resuscitation, then hundreds of thousands of babies, and many of their mothers, could be saved every year. To have the biggest impact we need to both strengthen health systems but also address barriers to using health care especially for the poor, including lack of recognition of childbirth complications, long distances to health facilities and high user fees" Dr. Lawn stated.

One of the reasons that birth asphyxia receives so little attention despite the large number of deaths is that most of these deaths are unseen and uncounted in South Asia and in sub-Saharan Africa. Often neither the birth nor the death is registered in official statistics. Fewer than 3 percent of the world's 4 million newborn deaths have death certificates with reliable cause of death information. Stillbirths are even less likely to be counted.

The authors stress that these are estimates and there is a need for better data. The Health Metrics Network, launched by the WHO in May 2005 and also funded by the Gates Foundation, will be working with countries to improve information on important but often invisible health problems such as birth asphyxia. Many of the world's 529,000 maternal deaths also occur as a consequence of complications during childbirth, and information is lacking for these deaths too.

As the authors conclude in their publication "innovative approaches are required to increase information for decision-making and improve care in settings where far too many babies do not cry at birth".

The study: Lawn JE, Shibuya, K, Stein C. No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths. Bulletin of the World Health Organization, 2005, June http://www.who.int/bulletin/en/index.html

World Health Organization. The World Health Report 2005. Making every mother and child count. Geneva: World Health Organization; 2005. http://www.who.int/whr/2005/en/ The Healthy Newborn Partnership. An interagency group of over 30 members including WHO, partnering to address newborn survival and health. http://www.healthynewborns.org/

Saving Newborn Lives. An initiative of the Save the Children US, funded by the Bill & Melinda Gates Foundation, and working with countries in Asia and Africa to answer operational research questions and to promote the integration and scaling up of interventions to save newborn lives. http://www.savethechildren.org/health/newborns/index.asp

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