Counting stillbirths and achieving accountability: A global health priority

Although the millennium development goals (MDGs) focused on maternal and child health and survival at inception, the importance of newborn survival to achievement of MDG 4 was soon well recognized [1].Over the last several years, the relative importance of stillbirths and their links to interventions to address maternal and newborn health have also been underscored [2].Despite this advocacy, the estimated 2.6 million stillbirths globally largely remain a hidden issue on the global policy platform, with little to no awareness for action at the country level [2].It took much effort towards the end of the MDG period to have stillbirth rates included as one of the 16 key indicators for monitoring progress for the global strategy for women, children, and adolescents [3].We need better data than modeled estimates to better define the burden and etiology of stillbirths from representative population-based studies or vital registration systems.The latter are relatively uncommon as the source of information in low-and middle-income settings.In this week's PLOS Medicine, Dandona and colleagues [4] underscore the importance of stillbirths in a population-based survey of Bihar (India).The study was based on verbal autopsies conducted on 1,132 stillbirths identified among 100,000 households over a 38-month period.Their identified incidence rate of stillbirths of 21.2 per 1,000 births (95% CI 19.7-22.6) is very close to the modeled estimated rate of 22 per 1,000 births [5].In a little over a third of these stillbirths, no cause could be identified, whereas obstetric complications and hemorrhage were associated with 30% of stillbirths.These findings are broadly consonant with the limited information on etiology from other studies of stillbirths [5,6].In a large verbal autopsy-based analysis of 1,285 stillbirths across a national sample of 95,000 households in the Pakistan demographic and health survey in 2006, 33.5% of antepartum stillbirths and 20.9% of intrapartum stillbirths did not have a clear cause of death [7].Many of the findings reported by Dandona et al [4] are well recognized risk factors for poor pregnancy outcomes, such as the association of stillbirths with poor quality of antenatal care (no antenatal care in 41% and 52% of urban or rural samples, respectively), small size of the fetus (25% and 38%), maternal fever in about 15%-16%, and evidence of infection in 15%-20% of subjects.No information is provided on the proportion of births among younger adolescents (<18 years), an important factor in the context of India, where adverse birth outcomes are associated with young maternal age [8].Similarly, we do not have information specific on access to caesarean section deliveries in the cohort, as limited access to emergency caesarean sections is a recognized risk factor for stillbirths at the population level [5].Given the lack of corresponding data on general births in Bihar or neonatal deaths, it is difficult to extrapolate the findings to beyond the stillbirth cohort.However, the risk factors are well known and do provide information relevant for policy.The authors relied on verbal narratives in their

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