key: cord-0727553-me8azprp authors: Hug, Lucia; You, Danzhen; Blencowe, Hannah; Mishra, Anu; Wang, Zhengfan; Fix, Miranda J; Wakefield, Jon; Moran, Allisyn C; Gaigbe-Togbe, Victor; Suzuki, Emi; Blau, Dianna M; Cousens, Simon; Creanga, Andreea; Croft, Trevor; Hill, Kenneth; Joseph, K S; Maswime, Salome; McClure, Elizabeth M; Pattinson, Robert; Pedersen, Jon; Smith, Lucy K; Zeitlin, Jennifer; Alkema, Leontine title: Global, regional, and national estimates and trends in stillbirths from 2000 to 2019: a systematic assessment date: 2021-08-28 journal: Lancet DOI: 10.1016/s0140-6736(21)01112-0 sha: 31e72ee5cfd72e2376fb9e7ca5e3362faaa80935 doc_id: 727553 cord_uid: me8azprp BACKGROUND: Stillbirths are a major public health issue and a sensitive marker of the quality of care around pregnancy and birth. The UN Global Strategy for Women's, Children's and Adolescents’ Health (2016–30) and the Every Newborn Action Plan (led by UNICEF and WHO) call for an end to preventable stillbirths. A first step to prevent stillbirths is obtaining standardised measurement of stillbirth rates across countries. We estimated stillbirth rates and their trends for 195 countries from 2000 to 2019 and assessed progress over time. METHODS: For a systematic assessment, we created a dataset of 2833 country-year datapoints from 171 countries relevant to stillbirth rates, including data from registration and health information systems, household-based surveys, and population-based studies. After data quality assessment and exclusions, we used 1531 datapoints to estimate country-specific stillbirth rates for 195 countries from 2000 to 2019 using a Bayesian hierarchical temporal sparse regression model, according to a definition of stillbirth of at least 28 weeks’ gestational age. Our model combined covariates with a temporal smoothing process such that estimates were informed by data for country-periods with high quality data, while being based on covariates for country-periods with little or no data on stillbirth rates. Bias and additional uncertainty associated with observations based on alternative stillbirth definitions and source types, and observations that were subject to non-sampling errors, were included in the model. We compared the estimated stillbirth rates and trends to previously reported mortality estimates in children younger than 5 years. FINDINGS: Globally in 2019, an estimated 2·0 million babies (90% uncertainty interval [UI] 1·9–2·2) were stillborn at 28 weeks or more of gestation, with a global stillbirth rate of 13·9 stillbirths (90% UI 13·5–15·4) per 1000 total births. Stillbirth rates in 2019 varied widely across regions, from 22·8 stillbirths (19·8–27·7) per 1000 total births in west and central Africa to 2·9 (2·7–3·0) in western Europe. After west and central Africa, eastern and southern Africa and south Asia had the second and third highest stillbirth rates in 2019. The global annual rate of reduction in stillbirth rate was estimated at 2·3% (90% UI 1·7–2·7) from 2000 to 2019, which was lower than the 2·9% (2·5–3·2) annual rate of reduction in neonatal mortality rate (for neonates aged <28 days) and the 4·3% (3·8–4·7) annual rate of reduction in mortality rate among children aged 1–59 months during the same period. Based on the lower bound of the 90% UIs, 114 countries had an estimated decrease in stillbirth rate since 2000, with four countries having a decrease of at least 50·0%, 28 having a decrease of 25·0–49·9%, 50 having a decrease of 10·0–24·9%, and 32 having a decrease of less than 10·0%. For the remaining 81 countries, we found no decrease in stillbirth rate since 2000. Of these countries, 34 were in sub-Saharan Africa, 16 were in east Asia and the Pacific, and 15 were in Latin America and the Caribbean. INTERPRETATION: Progress in reducing the rate of stillbirths has been slow compared with decreases in the mortality rate of children younger than 5 years. Accelerated improvements are most needed in the regions and countries with high stillbirth rates, particularly in sub-Saharan Africa. Future prevention of stillbirths needs increased efforts to raise public awareness, improve data collection, assess progress, and understand public health priorities locally, all of which require investment. FUNDING: Bill & Melinda Gates Foundation and the UK Foreign, Commonwealth and Development Office. : Share of stillbirths, percentage decrease, annual rate of change in stillbirth rate, neonatal mortality rate and mortality rate among children aged 1-59 months, and ratio of stillbirth to neonatal mortality rate, by country or territory .. The UN IGME's approach to estimate stillbirth rates (SBR) includes the following steps: 1. Compile all available stillbirth data at a country level, derived from administrative sources, household surveys or population-based studies. 2. Evaluate data in accordance with the data quality criteria and produce adjustment or recalculation by applying standardized definitions. 3. Estimate global and country-specific trends of stillbirth rates using a smoothing time series model, supplemented with covariates associated with stillbirth rates. This process averages empirical data on stillbirths derived from the different sources for a given country. In the case of countries with sparse or no data, the identified covariates associated with stillbirth will inform the trend in stillbirth rate. To increase the transparency of the estimation methodology and make stillbirth data available to users worldwide, UN IGME makes all data sources and stillbirth estimates available on its web portal at www.childmortality.org. 2.2 Data sources Estimates of stillbirth rates for a country are derived from various sources, such as administrative data (e.g. vital registration systems, birth or death registries, or health management information systems), household surveys, or from population-based studies obtained from a review of academic literature. Additionally, data on factors associated with stillbirth rate are collected, to be used as covariates in the stillbirth estimation model. Table A5 lists the covariates used in the stillbirth estimation model and data sources. The majority of administrative data comes from registration systems and health data systems including health management information systems (HMIS). Often data from registration systems record stillbirths and live births using detailed gestational age and/or birthweight. HMIS data are collected in health facilities and in many countries, the District Health Information System-2 (DHIS2) is the commonest HMIS data platform. 1 Few HMIS systems currently report detailed gestational age and/or birthweight data on stillbirths. Information on stillbirths in household surveys -such as such as the United States Agency for International Development (USAID)-supported Demographic and Health Surveys, Reproductive Health Survey (RHS) and the UNICEF-supported Multiple Indicator Cluster Surveys-are usually collected in two different ways: with a full pregnancy history; or with a reproductive calendar. 2 In the pregnancy history (PH), women of reproductive age are asked about all pregnancies in their lifetime. For each pregnancy they are asked to provide information on the duration of the pregnancy, the outcome of the pregnancy (e.g., miscarriage, stillbirth or livebirth) and the date of birth or end of pregnancy. In some surveys with PH modules the women were only asked whether they had a stillbirth and the date of the stillbirth. In these cases, a seven-month duration of pregnancy was assumed. In some survey-specific cases, a stillbirth was defined by the questionnaire as a fetal death occurring at the fifth or sixth month or later. PH data allow the calculation of stillbirth rates for specific time periods in the past. PH data allow to calculate stillbirth rates for specific time periods. For PH data, the stillbirth estimates were calculated for 5-year calendar year periods instead of the 5-year periods (as measured by up to 4 years prior to survey administration) preceding the survey. We calculated stillbirth rates for 5 intervals (e.g. 25 years), before the survey date. The most recent 5-year calendar period was included in the estimation model. In the reproductive calendar (RC), women are asked about the duration and month of pregnancy end for pregnancies that did not end in a live birth in the last 60 months. RCs are usually administered alongside a full birth history. In reproductive calendars the stillbirth rate is the number of pregnancies that are terminated in the seventh month or later of pregnancy divided by the number of pregnancies that reached at least the seventh month. The RC data allow the calculation of stillbirth rates for the 5-year period preceding the survey. However, stillbirth estimates from the RC were not included in the model if estimates from the PH in the same survey were available. Population-based study data were sought for all countries without high coverage of routine administrative data. The literature review undertaken for the previous stillbirth estimates 3 was updated through to 29 January 2019. In addition, further reanalyzed population-based stillbirth data were obtained from a WHO data call to maternal-newborn health experts. Data were excluded if: they lacked a clear source of definition or clear information on data collection systems; a high proportion of reported stillbirths had unknown gestational age or birthweight; data were internally inconsistent; or coverage of live births in administrative data systems was estimated below 80 per cent. Vital registration data with incomplete coverage of child deaths were also excluded. Consistency across data sources was further assessed by comparing stillbirth estimates to similar data sources within the same country and expected global and regional patterns in mortality. As part of the assessment of data quality, the plausibility of the ratio of stillbirth rates (measured as per 28 weeks of gestation or more definition) to neonatal mortality rates was assessed, by comparing these ratios to the distribution of ratios obtained from high-quality LMIC study data. High-quality LMIC study data is defined as population-based prospectively collected data with recruitment prior to 28 weeks of gestation, and follow-up to at least 28 days of age of live births. In assessing the SBR:NMR ratio in the input database, the NMR from the data source was used where available. Where data sources had missing NMR data, the estimated NMR by UN IGME was used. For observations from HMIS and population studies on stillbirths, the ratio of observed SBR to the UN IGME NMR was calculated and the same exclusion approach applied so that observations with extremely low SBR compared to national level NMR were excluded. In summary, the mean and variance of the settingspecific SBR:NMR ratios is estimated, assuming that each observed SBR:NMR ratio is the sum of a setting-specific SBR:NMR ratio and random stochastic error. If stillbirths were under-reported relative to neonatal deaths for a specific observation, its associated observed ratio of SBR to NMR would be lower than the true ratio. To quantify whether an observed ratio is 'extremely' low, the probability of observing a ratio that is smaller than the observed ratio was calculated (taking account of the uncertainty associated with the observed ratio) using the distribution of ratios obtained from the highquality data. If this probability was less than 0.05, the observation was excluded from the database. This approach was applied to all observations in the database with 28 weeks of gestation or more definitions and adjusted 28-week definitions. Data limitations necessitated some assumptions regarding definitional adjustments. For survey data, a seven-month duration of pregnancy is assumed to be equal to a 28-weeks or more definition. Further, in LMICs it is assumed that the SBR observed using a stillbirth definition of a birthweight of 1,000 grams or more is equal to the SBR observed using the 28 weeks of gestation or more definition, and similarly that the SBR observed with a birthweight of 500 grams or more definition equals the SBR observed with a 22 week of gestational age or more definition. Estimation and projection of stillbirth rates is undertaken using a statistical model for all country-years. In the model, the SBR is estimated assuming that the Observed log (SBR) = log (true SBR) + bias + measurement error where the true SBR in a country for years 2000 to 2020 = country-intercept + SBR predicted by covariates + country-specific temporal smoothing process. The bias refers to the definitional adjustment bias and source type bias. The measurement error refers to the stochastic sampling error, source type error, and additional error incurred from definitional adjustments. The model produces estimates of the SBR for years 2000 to 2020 with uncertainty. Full details on the estimation model and statistical methods are described in Wang et al 4 . The number of stillbirths in each country is calculated using the following formula: Number of stillbirths=livebirths * SBR/(1-SBR). The annual estimate of the number of live births in each country from the World Population Prospects: the 2019 revision 5 are used along with the UN IGME SBR estimates to calculate the estimated numbers of stillbirths. Slovakia >=10 19 12 19 12 0 0 0 0 0 0 Slovenia >=10 21 20 21 20 0 0 0 0 0 0 Solomon Islands >=10 19 18 19 18 0 Administrative Survey Vital Registration ( Population study Vital Registration ( Administrative HMIS Vital Registration ( Population study Vital Registration ( Population study Waiswa ( Population study Global Network Re-analysed ( Administrative Survey Vital Registration ( Administrative Survey Vital Registration ( Administrative Survey Birth or Death Registry (28wks) Vital Registration ( Population study Waiswa (28wks) Kaestrel 2005 Population study Administrative Survey Birth or Death Registry ( Administrative Survey Vital Registration ( Administrative HMIS Vital Registration ( Population study Administrative Survey Vital Registration (any gestational age or birthweight) Administrative Survey Vital Registration ( Administrative Survey Vital Registration ( Administrative HMIS Vital Registration ( Administrative HMIS Vital Registration (not defined) HMIS-DHIS2 ( Population study Population study Population study SBR (stillbirths per 1,000 total births) Data Included in the Model and Health Survey 2011-12 (Other) (PH) (28wks) Encuesta Nicaragüense de Demografía y Salud 2006 (RHS) (PH) (28wks) SBR (stillbirths per 1,000 total births) Available Data SBR (stillbirths per 1,000 total births) '28+ Weeks of Gestation' Data (Incl SBR (stillbirths per 1,000 total births) Data Sources Encuesta Demográfica y de Salud Familiar 2019 (DHS) (RC) (28wks) Demographic and Health Survey (Continuous) 2018 (DHS) (RC) (28wks) Demographic and Health Survey (Continuous) 2017 (DHS) (RC) (28wks) Encuesta Demográfica y de Salud Familiar 2014 (DHS) (RC) (28wks) Encuesta Demográfica y de Salud Familiar 2013 (DHS) (RC) (28wks) Encuesta Demográfica y de Salud Familiar 2012 (DHS) (RC) (28wks) Encuesta Demográfica y de Salud Familiar 2011 (DHS) (RC) (28wks) Encuesta Demográfica y de Salud Familiar 2010 (DHS) (RC) (28wks) Encuesta Demográfica y de Salud Familiar 2009 (DHS) (RC) (28wks) Demographic and Health Survey 2004-08 (DHS) (RC) (28wks) Encuesta Demográfica y de Salud Familiar 2007-08 (DHS) (RC) (28wks) Gonzales SBR SBR SBR (stillbirths per 1,000 total births) '28+ Weeks of Gestation' Data (Incl SBR (stillbirths per 1,000 total births) Data Included in the Model UN IGME Estimates Source Types HMIS Survey Data Sources HMIS-DHIS2 (28wks) Enquête Démographique et de Santé Continue 2017 (DHS) (RC) (28wks) Enquête Démographique et de Santé Continue 2015 (DHS) (RC) (28wks) SBR (stillbirths per 1,000 total births) Available Data SBR (stillbirths per 1,000 total births) '28+ Weeks of Gestation' Data (Incl SBR Birth or Death Registry (28wks) Population study Administrative Survey Vital Registration ( Vital Registration (28wks)