1. The Lancet’s Stillbirth Series Overview presentation can be adapted for relevant presentations Prepared on behalf of The Lancet Stillbirth Series Steering Committee Chris Taylor/Save the Children

2. Adapting this presentation Personalise with local photos. Consider adding country or regional-level data as comparison slides. Charts and graphs are based on best available data up to April 2011. Local examples of programmes or stories of personal loss Please credit The Lancet Stillbirth Series and link to the website

3. Presentation outline 1.Introduction 2.Stillbirth series – new data and analysis –Invisibility: Where? When? Why? –Interventions: evidence on what works –Implementation: integrated care has triple benefit 3.Stillbirth in high income countries –National report card UK 4.Reality – family story 5.2020 vision –Stillbirths matter –Goals and priorities 6.Response from United Nations representative PMNCH

4. Launches and media coverage London New York Australia Geneva New Delhi Florence, Italy Cape Town “These papers, like no other Lancet Series before, have triggered a remarkable response not just from academia and organisations, but also from the public” - The Lancet editors

5. The Lancet Stillbirth Series team Steering team of 7 members 69 authors from 18 countries Over 50 partner organizations Funding by all the partners, Bill & Melinda Gates Foundation as main funder

6. The Lancet’s Stillbirth Series: 6 papers 1.Invisibility of stillbirth: Making the unseen seen 2.Information to making stillbirths count: Where? When? Why? 3.Interventions: Evidence on what works 4.Implementation: Integrated care has triple benefit 5.High-income settings: Priority actions 6.2020 vision: Goals and research priorities All papers can be accessed free at www.thelancet.com/series/stillbirthwww.thelancet.com/series/stillbirth

7. The Lancet’s Stillbirth Series Research articles (2) Stillbirth rate estimate and trends for 193 countries Risk factors for stillbirth in high-income countries Commentaries (8) Lancet editors Parent’s perspective Professionals’ perspective and commitment Including stillbirths in family health Stillbirth estimates Stillbirth risk factors Inequalities in stillbirth Stillbirth and reproductive rights Executive summary – also available in French and Italian

8. Stillbirths don’t count … 1. Global data NOT routinely reported to World Health Organization NOT included in the Global Burden of Disease metrics NOT measured appropriately in most national surveys 2. Global goals eg Millennium Development Goals (MDGs) Stillbirths NOT counted in the MDGs although intimately linked to: – Maternal health in MDG 5 – Neonatal deaths, accounting for 41% of child deaths in MDG4 – Poverty (MDG 1) and girls’ education (MDG2) Stillbirths often missed in national or international health policy and programmes … Yet they count for families

9. Paper 2: Counting stillbirths What is new? New estimates of stillbirth rate for 193 countries –Partnership: Saving Newborn Lives/Save the Children, London School of Hygiene and Tropical Medicine and WHO with country consultation –Increased input data, better modelling: vital registration or national stillbirth registries, national household surveys, and studies identified through systematic searches. –Time trends from 1995 to 2009 (first time ever) New estimates of intrapartum stillbirths (during labour) Comparing causes of stillbirths Recommendations to improve and use data, plus research priorities ranking by experts Source: Lawn JE, Blencowe H, Pattinson R, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: Where? When? Why? How to make the data count? Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(10)62187-3.

10. Definition of stillbirth WHO definition of stillbirth is a birthweight of at least 1000 g or a gestational age of at least 28 weeks (third trimester stillbirth) –Essential for international comparability, poorly applied –New stillbirth estimates for 193 countries use WHO definition In some high-income countries other definitions are used –In UK stillbirths are counted from 24 weeks –In USA, Australia and New Zealand from 20 weeks If high income country stillbirth definitions were used for all countries then the global total would be much higher eg for USA with WHO definition 13,070, USA definition 27,500

11. Country variation in stillbirth rates Source: Lawn JE, Blencowe H, Pattinson R, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: Where? When? Why? How to make the data count? Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(10)62187-3. 10 countries account for 66% of the world’s stillbirths – and 66% of neonatal deaths and 60% of maternal deaths 1. India 2. Pakistan 3. Nigeria 4. China 5. Bangladesh 6. Dem Rep Congo 7. Ethiopia 8. Indonesia 9. Tanzania 10. Afghanistan Stillbirth rates (deaths per 1000 livebirths) Lowest countries 1.Finland (2) 2.Singapore (2) Highest countries 192. Nigeria (42) 193. Pakistan (47) Stillbirth rates (deaths per 1000 livebirths) Lowest countries 1.Finland (2) 2.Singapore (2) Highest countries 192. Nigeria (42) 193. Pakistan (47) 2.6 (2.08 to 3.79) million stillbirths 98% occur in low-income and middle-income countries

12. Stillbirths during labour – 1.2 million a year Source: Lawn JE, Blencowe H, Pattinson R, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: Where? When? Why? How to make the data count? Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(10)62187-3. The risk of stillbirth during labour (intrapartum) for an African woman is 50 times higher than for a woman in the UK. 55% of all stillbirths are for rural families in Africa, south Asia

13. Causes of stillbirths Estimates for stillbirth are impeded by more than 35 different classification systems The “big five” causes: 1.Childbirth complications 2.Maternal infections in pregnancy eg syphilis 3.Maternal conditions, especially hypertension and diabetes 4.Fetal growth restriction 5.Congenital abnormalities Source: Lawn JE, Blencowe H, Pattinson R, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: Where? When? Why? How to make the data count? Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(10)62187-3. These overlap with the causes of maternal and neonatal deaths Source: Lawn JE, Blencowe H, Pattinson R, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: Where? When? Why? How to make the data count? Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(10)62187-3.

14. Regional stillbirth rate trends and projections to 2020 Source: Lawn JE, Blencowe H, Pattinson R, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: Where? When? Why? How to make the data count? Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(10)62187-3. Latin America, Eurasia, and east Asia have made more progress than other regions Colombia, Mexico and China have halved their numbers of stillbirths; Sub-Saharan Africa and south Asia have the slowest rates of decline If the same progress continues, then by 2020 over 90% of all stillbirths will be in Africa and south Asia

15. Papers 3 and 4: Interventions and implementation What is new? Systematic reviews for interventions with effect on stillbirth –Effect of 35 interventions reviewed, 10 interventions selected Lives Saved Tool (LiST) and cost modelling –New module added to LiST to model stillbirth effect –How many stillbirths could be prevented in 68 priority countries? –How many mothers and newborns would also be saved? –Which interventions have the most effect and may be more feasible in low- income settings? –Running cost per year of the interventions Implementation priorities and integration of services Research priorities ranked for intervention and implementation Source: Pattinson R et al. Stillbirths: how can health systems deliver for mothers and babies? Lancet 2011. Flenady V, et al. Stillbirths: the way forward in high-income countries. Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(11)60064-0.

16. 10 evidence-based interventions for stillbirth Interventions considered in the model99% coverage StillbirthsReduction 1 Periconceptual folic acid fortification 27,0001% 2 Malaria in pregnancy - ITNs & IPTp 35,0001% 3 Syphilis screening and treatment 136,0005% 4 Hypertensive diseases in pregnancy and management 570002% 5 Diabetes screening and management 24,0001% 6 Fetal growth restriction management 107,0004% 7 Induction of labor at or beyond 41 completed weeks 52,0002% 8,9,10 Obstetric Care (3 levels of care) 696,00028% Total Stillbirths Averted 1,134,00045% Basic antenatal careAdvanced antenatal care Childbirth care Source: Pattinson R et al. Stillbirths: how can health systems deliver for mothers and babies? Lancet 2011. 1.1 million stillbirths could be prevented But need higher coverage and quality of care

17. Source: Pattinson R, Kerber K, Buchmann E, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: how can health systems deliver for mothers and babies? Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(10)62306-9. Preventing maternal and neonatal deaths and stillbirths Deaths prevented: Stillbirths 1.1 million (45%) Newborn deaths 1.4 (43%) Maternal deaths 201,000 (54%) TRIPLE RETURN ON INVESTMENT Childbirth care Basic antenatal Advanced antenatal

18. Highly cost effective Source: Pattinson R, Kerber K, Buchmann E, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: how can health systems deliver for mothers and babies? Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(10)62306-9. Childbirth care cost analysis Cost per maternal death prevented is US$54,350 Counting newborns and stillbirths this becomes $3,920 per death prevented Total additional running cost of $10.9 billion for the 68 priority countries per year for full coverage of care with 10 interventions for women, newborns and stillbirths plus 5 maternal and newborn specific interventions US $2.32 per year per person in the 68 priority countries Affordable especially given results of 2.7 million lives saved Investment in maternal health should count the full effect

19. Paper 5: High-income countries What is new? Stillbirth data and time trends from 13 countries Causes and maternal conditions using a comparable classification system Risk factors analysis –Systematic review of studies addressing lifestyle risk factors including obesity, advanced maternal age and smoking Research priorities ranking by experts Source: Flenady V, Middleton P, Smith GC, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: the way forward in high-income countries. Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(11)60064-0.

20. Stillbirths in high-income countries Source: Flenady V, Middleton P, Smith GC, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: the way forward in high-income countries. Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(11)60064-0. Differences between countries and within countries show that more reduction in stillbirth rates is achievable UK

21. Stillbirth for disadvantaged women in rich countries Women living in disadvantage have stillbirth rates around double that of non-disadvantaged and equal to some low and middle income countries: –eg US African-American, Indigenous women in Canada and Australia In UK there is major regional variation: –National = 4.7 per 1000 –Lowest = South West (3.9 per 1000) –Highest = East Midlands (5.2 per 1,000) Source: Flenady V, Middleton P, Smith GC, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: the way forward in high-income countries. Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(11)60064-0.

22. Main causes of stillbirth in high-income countries Placental (dysfunction with grow restriction and abruption) 30% Infection, largely associated with preterm birth 12% Congenital abnormalities 6% Maternal hypertension and diabetes <5% Unexplained (10 times SIDS numbers) 30% Source: Flenady V, Middleton P, Smith GC, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: the way forward in high-income countries. Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(11)60064-0. Risk factors for stillbirth: First birth 14% of stillbirths Maternal age over 35 years 11% Maternal overweight 12% Smoking 6 %

23. Women having stillbirth in UK >70% have no significant medical condition ~60% have not had any previous pregnancy complications 90% attend for antenatal care before 20 weeks 66% have never smoked 48% are in their first pregnancy Conclusion: Stillbirth can affect any women, not just those with problems or risk factors Source: CEMACE Report, 2009 Quote from a bereaved parent in late 2010: “If stillbirth really is ten times as common as cot death, we cannot be the only ones who had bought three sleep positioners but had never once considered the possibility of stillbirth”

24. Perinatal mortality audit Sub-optimal care contributes to around 30% of stillbirths. Audit against best practice standards can reduce stillbirth Most stillbirths are not thoroughly investigated and unexplained stillbirth may be overestimated by 50% Different approaches to classification of stillbirth causes means we have inadequate data to inform prevention Source: Flenady V, Middleton P, Smith GC, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: the way forward in high-income countries. Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(11)60064-0. Giovanni Presutti CiaoLapo

25. Priorities for action in high- income countries, including UK Address inequalities and lifestyle factors eg optimal weight and diet, smoking cessation Antenatal detection and management of women with risk factors –Detection of growth restriction, awareness of decreased fetal movements Improve quality of care, audit and investigations (including PM) Research: environmental determinants; fetal growth and placental function/dysfunction; turning knowledge into screening/intervention Source: Flenady V, Middleton P, Smith GC, et al,. Stillbirths: the way forward in high-income countries. Lancet 2011

26. Reality for families Over 7200 families a day experience a stillbirth… But every one is an individual, painful story Whether they are famous or not, in a rich country or poor, the grief is overwhelming, and usually hidden [Family story] Giovanni Presutti CiaoLapo

27. Paper 1: Stillbirths: Why they matter Invisibility from individual baby to global health agenda Source: Frøen JF, Cacciatore J, McClure EM, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: why they matter. Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(10)62232-5. Invisibility of the event and the individual baby Stigma and marginalization of the mother in communities Invisibility of numbers and medical causes Widespread fatalism regarding prevention opportunities Lacking national and international leadership

28. Paper 6: Stillbirths: the vision for 2020 Source: Goldenberg RL, McClure EM, Bhutta ZA, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: the vision for 2020. Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(10)62235-0. Woods R. Long-term trends in fetal mortality: implications for developing countries. Bull WHO 2008; 86: 460-6. Stillbirth rates halved 1950-1975 with improvements in infection treatment and obstetric care – feasible now and linked to reductions in maternal and neonatal mortality

29. Goal by 2020 Countries with a current stillbirth rate of less than 5 per 1000 births, the goal by 2020 is to eliminate all preventable stillbirths and close equity gaps Countries with a current stillbirth rate of more than 5 per 1000 births to reduce their stillbirth rates by at least 50% from the 2008 rates. All papers can be accessed free at www.thelancet.com/series/stillbirthwww.thelancet.com/series/stillbirth PMNCH Sands UK

30. International agencies Include stillbirth reduction in all relevant maternal and neonatal health initiatives Include stillbirth in all relevant international health reports Report accurate stillbirth rates and cause-of- death data Create a universal classification system Implement an effective business model to reduce stillbirths Sands UK Giovanni Presutti CiaoLapo

31. Individual countries Create a plan for stillbirth reduction Collect accurate data on stillbirth rates and causes of death Assess disparities in stillbirth rates by ethnic origin and location Audit stillbirths for causes and preventability Reduce stigma associated with stillbirth Sands UK Giovanni Presutti CiaoLapo

32. Communities and families Ensure empowerment for women and families Set up pregnancy improvement committees Provide birth plans and transportation Reduce stigma Provide bereavement support Sands UK Giovanni Presutti CiaoLapo

33. Global context – maternal and child health Need to accelerate progress towards MDGs 4 & 5: increasing concern to the international community. Global Strategy for Women’s and Children’s Health launched by UN Secretary-General, September 2010. Commission on Information and Accountability for Women’s and Children’s Health presented recommendations to UN General Assembly, September 2011. UN General Assembly special session on noncommunicable diseases (obesity/overweight, diabetes, hypertension – risk factors for stillbirth).

34. What needs to be done – better information Improved data on pregnancy outcomes, including stillbirths, is crucial to guiding programmes and investment towards achieving the MDGs and reducing stillbirths. Systematic collection of stillbirth data is required to better understand the scale of the problem and prioritize actions. –Efforts should be undertaken to strengthen national vital registration systems (for recording births and deaths) and include stillbirths. Without this information, programmes can't plan properly and allocate limited resources wisely. This will also help improve understanding of stillbirth as a public health problem, and have it recognized and accepted as such by health services providers everywhere.

35. What needs to be done – better access to care Stillbirths are closely linked with maternal and newborn health. Stillbirth rates are higher in countries where women have less access to good-quality care in pregnancy and childbirth. Improving access to interventions that reduce stillbirths will improve maternal and newborn health too (and vice versa). Comprehensive efforts must be made to strengthen the capacity of health services to deliver this care.

36. COUNTRY EXAMPLES TO ADAPT FROM (note data is for 2009)

37. Report card for stillbirths in South Africa Stillbirth data Number of stillbirths per year (2009), WHO definition Rank for numbers* 23,000 176 Stillbirth rate per 1000 births (2009), WHO definition Rank for rates* 20 148 Av annual rate of reduction 1995-2009 0.9% * From 193 countries 2000-2009 progress Stillbirth rate reduced from 23 to 20 per 1000 (12%, or <1% per year)

38. Snapshot of stillbirth in USA Stillbirth data for the USA Number of stillbirths per year (2009) 13,070 Rank out of 193 countries – numbers 156 Stillbirth rate per 1000 births (2009) 3.0 Rank out of 193 countries - rates 17 Rate of reduction 1995-2009 1.5% Important causes -Placental problems -Congenital abnormalities -Intrapartum causes -Maternal disorders -Pre-eclampsia -Infection Priority actionsTO ADD Priority actions: 1.Reduce inequity, intentionally designing policies and programmes to reach underserved women from poor communities or ethnic minorities 2.Improve quality of care and use audit to link to change, and 3.Address lifestyle risk factors such as obesity, smoking, and advanced maternal age

39. Report card for stillbirths in UK Stillbirth data for the UK Number of stillbirths per year (2009) WHO definition National definition (24 weeks) 2,630 4,100 Rank for numbers* 115 Stillbirth rate per 1000 births (2009) WHO definition 3.5 Rank for rates* 33 Av annual rate of reduction 1995-2009 1.4% * From 193 countries 2000-2009 progress Stillbirth rate reduced from 5.4 to 5.2 per 1000 (3.5%) Neonatal death rate reduced 3.9 to 3.2 per 1000 (17.9%) Neonatal deaths are declining about 5 times faster than stillbirths