We all know that child mortality rates are too high in the developing world and that persistent high levels of infant and under five child mortality are among the greatest failures of global health. However, as important as it is to measure and monitor progress on existing child health indicators, the use of these measures may be overlooking a very important component of child health in developing countries.

Currently the infant mortality rate is defined as deaths within the first year of birth per 1,000 LIVE births. Neonatal births is the number of births within the first month of life per 1,000 LIVE births. And so on… Easy, right?

Whenever I teach my students about the calculation of these measures, eventually someone asks the absolutely right question: what happens if the child is not born alive? That is, what if it is a stillbirth? Easy, it does not count. Yes, if a woman carries a child to near or even full term and for whatever reason the child is born dead that life counts for nothing in our measures of child mortality or in our measurement of burden of disease.

In developed countries, this omission seems to be discussed more in terms of a nuisance factor in the calculation and comparison of infant and other child mortality measures across countries. Even among developed countries, there is no one standard definition of a live birth and it has been speculated (mainly by countries with higher rates of infant mortality) that stringency in this definition might partially explain the differences across developed countries.

In developing countries, however, this omission is much, much more important. It has been estimated that there are approximately 3.3 million stillbirth worldwide every single year. To put this in perspective, it has been estimated that there are roughly 135 million live births per year of which 8.8 million of these children will die before their first birthday. Approximately 40% of those deaths, or about 3.5 million will happen during the first month. Stillbirths thus represent nearly an equivalent loss of life as neonatal mortality. It is huge. Plus, if we were to take these figure into consideration, it would mean that we are underestimating overall child mortality by some rather substantial margin. It has been estimated that if stillbirths were included among deaths, about half of all child mortality would occur before the child should have reached their first birthday.

In most of the international health literature, a stillbirth is frequently defined as the birth of a dead fetus that weighs at least 1000 g to a woman who has been pregnant for at least 27 or 28 weeks, although this definition is not standard in all settings (fetuses born more prematurely than 27 weeks or under 1,000 g are not considered viable births and don’t count as a birth at all). A stillbirth can be antepartum, meaning it took place prior to the onset of labor or it can be intrapartum, meaning that the death took place after the onset of labor. There are approximately 2 antepartum stillbirths for every intrapartum stillbirth globally.

The distribution on child mortality for live births over time kind of looks like the side of a skill hill (yes, I have Olympic fever). Deaths are heavily concentrated in the first few days of life and declining steeply but steadily over time. (OK, this is a gross oversimplification). It is estimated that 75% of neonatal deaths are actually take place within the first week of life, and I am sure a similar pattern would hold within the first week of life as well. So if we really want to target neonatal deaths we need to focus on interventions that take place in the first few days of life, ideally starting during the delivery process.

There are low-cost interventions out there that are thought to improve neonatal outmodes: training in resuscitation, kangaroo care, thermoregulation, immediate breastfeeding, etc. A recent evaluation of a package of these interventions led to a somewhat surprising outcome: the training package had little impact on measures of neonatal mortality, despite showing evidence that coverage of these indicators increased due to the intervention.

After finding this null result, the authors conducted a secondary analysis of their data and showed a marginally significant reduction in the rate of stillborns in the intervention. Although not conclusive, one interpretation of these results is that the intervention may have saved a number of children who would otherwise have been born dead, bringing more marginally unhealthy children alive and thus biasing their measures of neonatal mortality upwards.

What did this study show? One, I think it shows that we still have a lot to learn about what actually improves outcomes of newborns during the first week of life. But as well, I think this study really highlights the arbitrary nature of our standard definitions of live vs. still births. To get a real measure of the human life lost during the late stages of pregnancy and in early life we may really want to capture the loss of children who die just moments before making their entry into the world.

Last week I started the third trimester of my first pregnancy. My baby is a really active little creature, kicking and moving throughout the day – and throughout the night – constantly inflicting pain and damage to my ribs and internal organs. To me, it is very much alive now and I find it disturbing that should something happen between now and when my child takes his first breath on the outside world its death would not count, essentially saying that as a society we do not care. We need to also understand what happens during this important stage of life and what can be done to improve outcomes in the late stages of pregnancy.

To find out more about this issue, there is a new organization called the Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), which is funded by the Bill and Melinda Gates Foundation. They have just released a report on this issue today and I would highly recommend that you take a look. There is also a great video with more information on this topic.

You can also click on the above photo, which is taken from the GAPPS website to link directly to their website.

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1 Response » to “The neglect of premature and stillborn deaths”

  1. […] blogged in the past about the complete neglect of stillbirths in the global burden of disease. Only children who are born alive count towards our measures of […]

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