Stillbirth is a devastating occurrence for families, and women bear the brunt of the consequences.1, 2 Hopes and dreams are dashed, and expectant women might suddenly face scorn, isolation, and rejection. They can be pressured to become pregnant again soon, and hence face a shortened birth interval and an increased risk for themselves and for subsequent pregnancies. This cycle continues—unbroken and unvoiced—every day in homes and communities around the world, especially in poor families.
The Lancet's Stillbirths Series is a landmark summation of the causes and global burden of stillbirths, along with a framework to deliver solutions within the context of reproductive, maternal and child health, and nutrition programmes, and a rallying cry for collective action. The Series builds on several recent reviews3—6 that have shaped the evidence base needed to address the problem.
This Series now authoritatively identifies stillbirth as one of the most shamefully neglected areas of public health. Although stillbirth is a universal problem, and exists along a spectrum of intrapartum stillbirths and intrapartum-related neonatal deaths (ie, birth asphyxia), the burden is woefully inequitable. Series authors J Frederik Frøen and colleagues1 point out that stillbirth rates in low-income countries are now where they were in high-income countries 50—100 years ago. They conclude that by simply addressing this inequity, bringing global stillbirth rates down to the average of low-burden settings, four in five stillbirths would be eliminated. The stillbirth burden, as enormous as it is with 2·6 million born dead after 28 weeks' gestation (an estimate from Simon Cousens and colleagues7 in another Series paper) is grossly underestimated. Such underestimation is due to under-reporting, inconsistent definitions, and the fact that stillbirths do not feature in major global or national health targets and commitments, in part because no global health constituency has taken full ownership of the problem.
This Series makes major strategic advances to show that the way to address the problem of stillbirth is to strengthen existing maternal, newborn, and child health programmes by focusing on a few key interventions, which also have benefits for mothers and neonates. If implemented, according to Zulfiqar Bhutta and co-workers8 in the Series, 15 proven antenatal and intrapartum interventions—ten of them also effective for averting stillbirths—could avert more than 2·7 million deaths of mothers and neonates, and stillbirths, each year by 2015. Tools are already available and a strong case has been made for their benefits for mothers and neonates;9—11 no new stillbirth-specific interventions, delivery platforms, or health-system elements are needed, a point made by Series authors Robert Pattinson and colleagues.12 What is needed, however, is a change in our framing of the continuum of care to include stillbirths.
The Stillbirths Series further emphasises the critical nature of the intrapartum period as a narrow window for intervention, when nearly half of stillbirths, three-quarters of maternal deaths, and one-quarter of newborn deaths occur (totalling 2·3 million deaths). If all we did was to provide good-quality care during childbirth, at a cost of less than US$1 per head, we could avert 1·4 million deaths of mothers and neonates, and stillbirths, each year. The stillbirths and newborn deaths that could be averted in addition to maternal deaths substantially strengthen the argument for childbirth care, which safe-motherhood advocates have been making for decades. In one of the more illuminating analyses in the Series, Pattinson and colleagues12 show that, if maternal deaths are only considered in deriving cost-effectiveness estimates of obstetric care, the figure of US$54 347 per death averted is not cost effective. When the stillbirths and neonatal deaths averted by these same interventions are also considered, the cost-effectiveness estimate improves dramatically to $3920 per death averted. Figures such as these show why advocates across all of women's and children's health should rally together to count and address stillbirth, and ensure integration of this issue into the continuum of care.
Antenatal care might play an important part in reducing the number of stillbirths in ways that current modelling does not take into account, for example, as a gateway behaviour associated with the uptake of other health-promoting behaviours. Family planning probably also has an important role, but its effect on stillbirth reduction was not modelled in this Series either. Selected nutritional interventions reduce stillbirths, but links between nutrition, infection, and susceptibility to hypoxic insults need further elucidation,13 as does the role of improved adolescent and maternal nutrition.
To improve women's and children's health, we need to optimise every interaction families have with the health system, particularly with frontline workers. Families should be empowered as producers of good health themselves, through the adoption of improved preventive and promotive practices, and care-seeking for complications. Simultaneously, frontline workers' capabilities, performance, and connections to the health system must be enhanced so they can provide more timely and effective counsel and care.14
Stillbirth is a major global public health problem and its day has come. New research is needed to improve our ability to prevent 60% of the stillbirth burden that cannot be averted with current interventions.8, 12 Meanwhile, inclusion of stillbirth when designing integrated family health programmes, and improving collection of stillbirth data, are important first steps to address this issue while also advancing the continuum of care.
I declare that I have no conflicts of interest.
References
1 . Stillbirths: why they matter. Lancet 201110.1016/S0140-6736(10)62232-5. published online April 14. PubMed
2 . “These are not good things for other people to know”: how women's understandings of pregnancy loss and early neonatal death in southern Tanzania may impact survey data quality. Soc Sci Med 2010; 71: 1764-1772. CrossRef | PubMed
3 . Reducing intrapartum-related deaths and disability: can the health system deliver?. Int J Obstet Gynecol 2009; 107: S123-S142. PubMed
4 . Delivering interventions to reduce the global burden of stillbirths: improving service supply and community demand. BMC Pregnancy Childbirth 2009; 9 (suppl 1): S7. CrossRef | PubMed
5 . Global report on preterm birth and stillbirth (7 of 7): mobilizing resources to accelerate innovative solutions (Global Action Agenda). BMC Pregnancy Childbirth 2010; 10 (suppl 1): S7. PubMed
6 . Stillbirths: epidemiology, evidence and priorities for action. Semin Perinatol 2010; 34: 387-394. CrossRef | PubMed
7 . National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet 201110.1016/S0140-6736(10)62310-0. published online April 14. PubMed
8 . Stillbirths: what difference can we make and at what cost?. Lancet 201110.1016/S0140-6736(10)62050-8. published online April 14. PubMed
9 . Evidence-based, cost-effective interventions: how many newborn babies can we save?. Lancet 2005; 365: 977-988. Summary | Full Text | PDF(147KB) | CrossRef | PubMed
10 . Interventions to address maternal, newborn, and child survival: what difference can integrated primary health care strategies make?. Lancet 2008; 372: 972-989. Summary | Full Text | PDF(340KB) | CrossRef | PubMed
11 . Strategies for reducing maternal mortality: getting on with what works. Lancet 2006; 368: 1284-1299. Summary | Full Text | PDF(296KB) | CrossRef | PubMed
12 . Stillbirths: how can health systems deliver for mothers and babies?. Lancet 201110.1016/S0140-6736(10)62306-9. published online April 14. PubMed
13 . Risk factors for birth asphyxia mortality in a community-based setting in Southern Nepal. Pediatrics 2008; 121: e1381-e1390. CrossRef | PubMed
14 . Behavior change for newborn survival in resource-poor community settings: bridging the gap between evidence and impact. Semin Perinatol 2010; 34: 446-461. CrossRef | PubMed
I understand a lot of very valuable information and meaningful knowledge.
返信削除uk writers
Pretty good post, this is one of the best articles that I have ever seen !
返信削除research paper