We present the inaugural (2021) version of the Scorecard for Ending Preventable Stillbirths in High- and Upper-Middle Income Countries along with data from 13 countries, representing 47% and 8% of all stillbirths among high- and upper-middle income countries, respectively [5]. Importantly, the scorecard shows that wide disparities persist between and within countries. This work has highlighted some of the important data challenges that need to be addressed to better understand these disparities and inform commensurate investments and programmatic action to close these. Differences in definitions of stillbirth and related perinatal outcomes persist limiting comparability between settings and over time, and data on important risk factors are frequently lacking. However, where data are available, context-specific relevant data disaggregation can provide a useful tool for tracking and accountability towards closing equity gaps. The Scorecard also identifies gaps in policies, guidelines and targets on key areas required for effective stillbirth prevention and care, such as a lack of SBR targets and quality-related data for stillbirth prevention and bereavement care found in the majority of countries included. The myth that stillbirths are not preventable [31], is contradicted by the data presented here, including both variability in SBRs across H/UMIC and improvements over time in some H/UMIC showing that a reduction in SBRs to match that of the best-performing countries globally is not only necessary but possible. This notion is further supported by a retrospective audit of late gestation perinatal deaths in Australia, which revealed that a large proportion of deaths was associated with suboptimal care [32]. A MBRRACE-UK (Mothers and Babies: Reducing Risk Through Audit and Confidential Enquiries – United Kingdom) perinatal confidential enquiry is currently investigating the quality of care provision in the UK [33].
A core component of the Lancet EPS series Call to Action was for all countries to set and meet targets to close equity gaps in the stillbirth rate and to use data to track and prevent these stillbirths [17]. Six years later, the Scorecard shows that equity gaps for stillbirths in H/UMIC persist. In the Australian setting, socially and economically disadvantaged groups such as Aboriginal and Torres Strait Islander peoples and other ethnic populations and rural and remote groups experience approximately twice the rate of stillbirth as the Australian average [13]. In the USA, racial disparities in stillbirth include a two-fold higher SBR among Black ethnicities as compared to white women [34]. In the UK, ethnic inequalities play a key role in stillbirth inequity [35]; the 2020 SBR among Black African babies was 7.8 per 1,000 total births, compared to 3.4 stillbirths per 1,000 total births for babies of white ethnicity [33]. The latest MBRRACE-UK Perinatal Mortality Surveillance Report (2022) highlighted the combined impact of deprivation and ethnicity on SBRs, with rates ranging from 2.8 to 8.1 per 1,000 total births depending on these characteristics [33]. Other HIC such as NZ and Spain experience similar inequalities, unique to their own settings [12,36]. Australia has currently set a SBR equity target in the NSAIP, aiming for stillbirth rates among women who live in rural and remote or socially disadvantaged areas, or are younger than 20 years, that are equal to those in the general population [23].
Of the 13 countries whose data is presented in the Scorecard, Australia is the first to have a government-led call for a reduction in stillbirth disparities between population groups. As with stillbirths in the population at large, stillbirths among disadvantaged groups are often preventable, but further action is needed to remove equity gaps [37]. Several successful interventions are known. The implementation of a culturally safe, evidence-based model of care for Aboriginal and Torres Strait Islander pregnant women in Australia (Birthing on Country service) resulted in significant improvements in antenatal care attendance and preterm birth rates [38], which are both important risk factors for stillbirth. The MAMAACT intervention in Denmark [39], and the MAMTA Child and Maternal Health Program for Black and Minority Ethnic Women in Coventry, UK [40], are two other examples of educational programs designed to improve maternal health and perinatal outcomes among ethnic populations which have also had success. More emphasis on public awareness campaigns for stigma reduction and education with a focus on disadvantaged populations may be helpful, including evaluation of such programs.
Another well-known issue highlighted by the Scorecard is the lack of comparability of data, due to differences in definitions of stillbirth and related perinatal outcomes between HIC as well as the lack of a single classification system for cause of death and contributing factors [41,42]. This reduces our ability to understand where progress is being made and to identify roadblocks. For instance, a slowing rate of reduction in SBRs in some countries [7], or in some countries an actual increase in SBRs at earlier gestations [20,43], may be driven in part by the inclusion of late pregnancy terminations in stillbirth data [44]. Varying definitions of stillbirth may also be responsible for at least some of the variation in SBRs between HIC, although a study by Zeitlin et al. (2019) on stillbirth rates in 31 European countries using 2015 Euro-Peristat data found that variation could not be explained by differences in reporting practices alone, as 28-week stillbirth rates varied from <2.3/1,000 total births (Cyprus, Iceland, Denmark, Finland and the Netherlands) to >3.5/1,000 total births (Slovakia, Romania, Hungary and Bulgaria) [45]. The common use of a 28-week gestational age cut-off for SBRs, while addressing data comparability issues, underestimates the real burden in most HIC where a significant proportion of stillbirths (35% to 50%, depending on definitions) occur between 20 and 27 completed weeks gestation [20]. Noncomparability of data on stillbirth causes and conditions associated with stillbirth could be resolved by the introduction and uptake of an international classification system. The ISA Prevention Working Group, in partnership with the Stillbirth CRE, is developing a standardized, high-quality classification system for conditions associated with stillbirth and neonatal death for use in data-rich settings [46], in alignment with recommendations from the WHO guidelines for perinatal mortality, that would meet this need [47].
Data for the 23 indicators in this inaugural version of the Scorecard were collected between 2011 and 2020, suggesting that what matters most for stillbirth prevention and care—not only stillbirth numbers but also factors such as the numbers of adolescent pregnancies and perinatal pathologists—is not tracked consistently. Stillbirth prevention is included in ENAP and the UN Global Strategy for Women’s, Children’s and Adolescents’ Health 2016-30, but was excluded from the Sustainable Development Goals, and global monitoring of SBR trends remains limited and challenged by data quality and other roadblocks [5]. We should continue to advocate for the inclusion of stillbirths in routine perinatal data collection to highlight the global burden [5]. Failing to collect and report data on stillbirths and their risk factors will have a significantly greater impact on population groups whose stillbirth burden is already disproportionately greater. The unforeseen global outbreak of Covid-19 has had a significant impact on stillbirth risk [48,49], further emphasizing the importance of having appropriate stillbirth reporting strategies and systems in place [50].
Interventions and investigations into stillbirth risk factors and causes are making important strides in reducing national stillbirth rates. Bundles of care for stillbirth prevention implemented in Australia [51,52], the UK [53], and Scotland [54], have the potential to reduce stillbirth rates and should be adapted and expanded globally. High-quality perinatal mortality audits are essential for continued learning on causes of stillbirth and the identification of risk factors [20]. However, previous research including for the Lancet EPS series has highlighted that very few H/UMIC have a national perinatal audit system, aligned with our finding that audit systems were lacking in about half of the 13 included countries [20,55]. Australia’s Improving Perinatal Mortality Review and Outcomes Via Education (IMPROVE) educational program [56], is one promising approach to address this challenge. IMPROVE aims to support clinicians in best practice care for women and families after perinatal death, including investigation and audit; the program has been well received in Australia and is available elsewhere through ISA [56].
Strengths and limitations
Over the past decade, a few studies have compared national SBRs [5,20,57,], and there are several comparison tools for SBRs and other related indicators for stillbirth prevention, such as the data visualization tools available on the Healthy Newborn Network website [58]. However, this inaugural (2021) version of the H/UMIC Scorecard is the first tool created to measure progress on stillbirth prevention and bereavement care in H/UMIC against the Lancet’s 2016 EPS Call to Action. The Scorecard provides H/UMIC civil society with a tool to foster transparency, consistency and accountability for stillbirth prevention and care at national, subnational and global levels, as well as helping to systematically assess progress and roadblocks over time (both between and within countries) and to promote collaboration in addressing stillbirth. There was also a relatively high coverage for high-income countries stillbirths (47%).
The Scorecard has some limitations. First, despite several attempts to reach potential country contacts, we only succeeded in engaging a limited number for this study. Only 30% of the country contacts we reached out to provided data, and these represent just 10% of all 135 H/UMIC that could potentially use this Scorecard [19]. Thus, the results presented in this paper do not reflect the stillbirth situation in all H/UMIC. One of the major difficulties was finding appropriate stillbirth contacts, which is related to the limited awareness of the stillbirth burden in these countries. A way to increase the numbers of H/UMIC tracked by this Scorecard would be to identify point persons or point agencies responsible for stillbirth and related perinatal outcomes at country level, as in done NZ where the Perinatal and Maternal Mortality Review Committee is responsible for collection and reporting of stillbirth data [12].
Second, data were not collected from governments directly, which could limit H/UMIC government acceptance of conclusions drawn from the Scorecard. Potential bias may have also been introduced by our country contacts, due to the subjective nature of some of the indicators in this scorecard. However, pulling data from multiple sources also allowed us to address the fact that some indicator data, such as stillbirth equity data and rates of planned pregnancy, are not routinely tracked in national reporting systems. The fact that SBRs presented in the Scorecard are consistent with 2020 data published by the United Nations Inter-agency Group for Child Mortality Estimation additionally increases confidence that the data reported by country contacts are accurate [59].
Third, data quality for some indicators was low. For instance, stillbirths in Spain were likely under-reported by as much as 5-10% for stillbirths ≥28 weeks gestation and 50% for stillbirths <28 weeks gestation [60,61]. Hence, the data presented in this Scorecard represents a minimum SBR and the SBR in Spain is likely much higher than reported here. Also, the fact that some of the data were up to a decade old, despite our request for the ‘most recent available data’, suggests limitations of data collection or availability that may also affect quality.
Next steps
First, we propose to further improve the quality of this Scorecard by carrying out a Delphi survey among key stakeholders (including parents), to check our 23 selected indicators, further define them, and identify any additional gaps in relevant data that should be included, as well as adjusting how indicators are reported, tracked and compared over time. Delphi surveys have been a successful tool for stillbirth prevention, such as for the development of a global classification system for causes of perinatal deaths [46]. In the Scorecard, quality indicators are currently reported as ‘present or ‘absent’, so do not reflect underlying quality, e.g. of the national stillbirth research program or perinatal pathology cadre. The dichotomous nature of these indicators hence does not allow for nuanced assessment. For example, although the Netherlands currently does not have a separate government-funded stillbirth research program, there are individual funding opportunities for research into adverse obstetric outcomes including stillbirth. To better quantify progress in and between H/UMIC, the current indicators need to be adjusted to increase their utility as measures of quality of stillbirth prevention and care after stillbirth. Similarly, H/UMIC targets for stillbirth and related perinatal outcomes could be set based on feedback from the Delphi survey, to enable benchmarking of country performance. We also aim to develop an indicator for data quality in future versions of the Scorecard. This could be based on a set of standards that assess key factors such as underreporting, data completeness, efficacy of the reporting system and correct differentiation of types of perinatal death. With similar antecedent risk factors and causal pathways leading to ENND, PTB, admission to neonatal care units and other adverse events, future versions of the Scorecard should also include indicators to help assess whether preventing stillbirth increases the incidence of these other outcomes. For example, measures to reduce stillbirth such as iatrogenic delivery, may result in a larger proportion of early term births (<39 weeks gestation), which has been associated with several short and long term health consequences in the newborn, like respiratory distress, hypoglycemia, jaundice, neurodevelopmental disorders or even neonatal death [62].
Second, high- and upper-middle income countries were selected for this Scorecard using World Bank definitions. However, although neither GDP per capita nor the Gini Index were correlated with ≥28 week SBRs (after removing Brazil as an outlier)—which is consistent with previous findings [63]—the Gini Index did seem to be a more sensitive measure of stillbirth risk [64]. Hence, consideration should be given to selection of countries for the Scorecard based on the Gini Index.
Third, the Scorecard was designed as a reporting tool to track progress both between and within H/UMIC, helping to identify areas for improvement. The Scorecard indicators are being used in the Australian NSAIP, which has an underlying focus on reducing stillbirth inequity [23]. Measuring progress will also help in assessing whether the indicators in the Scorecard are the right ones—whether they make a difference for the stillbirth burden. We aim to present an updated report biannually, and to motivate an increasing number of high- and upper-middle income countries to participate in the Scorecard. Finally, we propose to use the Scorecard to advocate for key changes globally. For example, a common definition of stillbirth specific to H/UMIC should be developed to help track progress and increase comparability.