The International Federation of Gynecology and Obstetrics (FIGO), the International Paediatric Association (IPA), and the International Confederation of Midwives (ICM) are well aware of the often forgotten issue of stillbirth, and recognise it as one of the most common adverse pregnancy outcomes worldwide—with about 2·6 million or more stillbirths happening every year.1 The explanation for many of these deaths is straightforward and terrible: all too often a trained health worker is not available when an expectant mother or woman in labour faces a situation endangering her baby's life. When confronted with a stillbirth, obstetricians, midwives, and paediatricians have to contend not only with the loss of life, but also the distress of parents and disappointment of family at a time that should be joyous and about bringing a new life into the world. Furthermore, the outcome of the next pregnancy is often a major concern for parents, because a previous stillbirth is, depending on the population, associated with a two-fold to four-fold increased risk2—4 of recurrence compared with women who have had a previous livebirth. Additionally, risk of pregnancy and birth complications in the subsequent pregnancy is heightened.5
Maternal and fetal outcomes at birth are a sensitive indicator of the status of health systems. They show the quality of care that is available to manage maternal and fetal life-threatening complications, which are often unpredictable and need a rapid, skilled response and access to tertiary emergency obstetric services, including well coordinated teamwork between obstetricians, midwives, and paediatricians. Access to such services in 33 of 51 Countdown countries is poor, resulting in rural coverage rates for caesarean section below 5%, which are indicative of challenges to human resources and other health systems. Four countries, Burkina Faso, Chad, Ethiopia, and Niger, have rural rates below 1%.6 Only 15 Countdown countries meet the crucial threshold of 23 doctors, nurses, and midwives per 10 000 people. These numbers are estimated to be necessary to ensure that 80% of all births have assistance from a skilled attendant to deliver essential health services.7 This shortage is compounded by uneven geographical distribution of these health-care workers within countries.8
FIGO's mission to improve women's health, rights, and access to reproductive and sexual health services, and reduce disparities in health care for women and newborn babies places prevention and management of stillbirth in the centre of its interest and activities.9 The ultimate goal of obstetricians, midwives, and paediatricians is that every pregnancy is wanted, every birth safe, every newborn baby healthy, and every woman, including adolescents, treated with dignity and respect. In cases of stillbirth, obstetricians, midwives, and paediatricians face the psychological and emotional issues arising for women, their partners, and families. Unfortunately, many of these women and couples do not receive comprehensive counselling about the reasons behind the stillbirth, the potential for it to recur, and how to prevent it in a subsequent pregnancy. Because a definitive cause cannot be identified in about half of cases,2 stillbirth baffles obstetricians, midwives, neonatologists, and paediatricians, making counselling very difficult, even in developed countries where advances in socioeconomic standards and high-quality antenatal and intrapartum care have contributed to reduced rates.
Obstetricians, midwives, and paediatricians should be pleased that The Lancet has published a Series on this important health issue. We believe that FIGO, IPA, and ICM have a major part to play in saving the lives of millions of stillborn babies worldwide, especially in developing countries. We must also address the distress of millions of couples who are affected. At the microlevel, obstetricians, midwives, and paediatricians can contribute to important measures such as advocacy, health education, high-quality health-care services during pregnancy and childbirth, including addressing the leading causes of stillbirths, and access to emergency obstetric care when needed. We must also work together to provide proper informative and supportive counselling of parents of a stillborn baby. At the macrolevel, these three organisations can make a difference through advocacy, partnership with UN and other organisations, training and education, capacity building of member associations to provide high-quality maternal and neonatology care, and task shifting when specialists are in short supply.10
GIS is the President of FIGO, SAC is the President of IPA, and BL is the President of ICM.
References
1 . 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
2 . Recurrence risk of stillbirth in the second pregnancy. BJOG 2010; 117: 1173-1174. CrossRef | PubMed
3 . Stillbirth recurrence in a population of relatively low risk mothers. Paediatric Perinat Epidemiol 2007; 21 (supp 1): 24-30. PubMed
5 . Obstetric outcomes subsequent to intrauterine death in the first pregnancy. BJOG 2008; 115: 269-274. CrossRef | PubMed
6 . Countdown to 2015: decade report (2000—2010). Taking stock of maternal, newborn and child survival. http://www.countdown2015mnch.org/documents/2010report/CountdownReportOnly.pdf. (accessed Jan 16, 2011).
7 . Working together for health: the world health report 2006. http://www.who.int/whr/2006/whr06_en.pdf. (accessed Jan 16, 2011).
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