True burden of stillbirths in Europe vastly underestimated, research shows

The burden of stillbirth has been underestimated by at least a third because of recommendations to report only stillbirths from 28 weeks’ gestation in international comparisons, according to an observational study of 2.5 million babies in 19 European countries led by the University of Leicester and published in The Lancet.  

The findings underscore the importance of accurate and consistent reporting of fetal deaths as early as 22 weeks so that the true burden of stillbirth can be understood and the impact on families acknowledged. 

“There are major and serious gaps in our knowledge of the burden of stillbirth which will have significant unforeseen impacts on families,” says Dr Lucy Smith from the University’s Department of Health Sciences, who led the research. “To a mother or father, a second trimester stillbirth is no less tragic than a stillbirth at 28 weeks of pregnancy or later. These parents also deserve recognition of their loss and accurate reporting of their child’s death to improve care and policy.” 

The authors used data from 19 European countries on pregnancy outcomes from 22 weeks of gestation between 2004 and 2015, to calculate overall rates of stillbirth and changes in rates between 2004 and 2015 by gestational age and country. 

In 2015, more than 9300 babies were stillborn from 2.5 million births in Europe, and out of these a third were stillborn between 22 and less than 28 weeks of gestation, and would have been excluded from WHO’s threshold for international comparison. 

Between 2004 and 2015, the overall stillbirth rate between 24 and less than 28 weeks of gestation declined from nearly 10 to 7 per 10,000 total births, a reduction of 25% (figure 1B). This is similar to global figures of stillbirths over 28 weeks of gestation which fell 25.5% worldwide (from 247 to 184 per 10,000 births) and 24.5% in developed regions (from 45 to 34 per 10,000 births) between 2000 and 2015—suggesting consistent improvements in the reduction of stillbirths from 24 weeks of gestation over time.

Nevertheless, the variation across countries in stillbirths from 24 to less than 28 weeks in Europe ranged between 4 and 8 per 10,000 total births (when excluding terminations of pregnancy) implying that a large proportion of stillbirths are still preventable. These results are consistent with the variation in stillbirth rates at later gestation observed in many previous studies in high-income countries. The authors point out that the consistency in reporting of these earlier stillbirths suggests that these deaths should be routinely included in international comparisons to help inform clinical practice and policy.

In contrast, the overall rate of stillbirth between 22 and less than 24 weeks has remained unchanged since 2004, at around 5 per 10,000 births in 2015. The authors speculate that this is likely to be due to improvements in the reporting of deaths at these gestations. In 2015, rates of stillbirth (22 to <24 weeks) varied 6-fold between countries ranging from more than 2 per 10,000 births to 17 per 10,000 births (figure 1A). 

According to Dr Smith: “Wide variation in the number of stillbirths occurring between 22 weeks and 24 weeks is likely to highlight differences in the collection of data across European countries rather than variation in underlying stillbirth risk. To ensure that the true magnitude and burden of stillbirth is understood, and to improve routine data collection for monitoring the outcomes and management of extremely preterm births from 22 weeks gestation, WHO’s threshold for high-income country comparisons should be lowered.” 

The authors note some limitations including that late terminations of pregnancy could not be excluded in a few countries, and the omission of some countries because of lack of comparable data for the study period, may have influenced the results—although sensitivity analyses supported the generalisability of the results as proportions of early stillbirths in these countries were very similar.

The team has created a resource for parents who have experienced loss. The interviews were undertaken in the UK and the website aims to support parents, loved ones and health professionals who have experienced loss before 24 weeks of pregnancy. You can watch videos of parents talking about topics such as finding out something was wrong, experiences of labour and giving birth, seeing and spending time with their baby, making memories and the long term emotional impact.

Dr Lucy Smith has discussed the underestimation of stillbirth in Europe, and the global priorities for recognising stillbirth within the sustainable development agenda, as part of a podcast for The Lancet.