the lancet’s stillbirth series - gyn bethlehem 2012 · 2012-03-15 · • monir islam (in / who)...

The Lancet’s Stillbirth Series

J. Frederik Frøen MD PhD

Norwegian Institute of Public Health, Oslo

& International Stillbirth Alliance

On behalf of The Lancet Stillbirth Series Steering Committee

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The team

• Steering team of 7 members

• 69 authors from 18 countries

• Over 50 partner organizations

• Funding by all the partners,

Bill & Melinda Gates

Foundation as main funder

The Lancet Stillbirth Series Steering Committee

• J. Frederik Frøen (NO)

• Joy E. Lawn (SA)

• Zulfiqar Bhutta (PK)

• Robert Pattinson (SA)

• Robert L. Goldenberg (USA)

• Vicki Flenady (AUS)

• Monir Islam (IN / WHO)

Series Steering Committee: JF Frøen, JE Lawn, Z Bhutta, RC Pattinson, V Flenady, RL Goldenberg and M Islam.

Frøen JF, Cacciatore J, McClure EM, Kuti O, Jokhio AH, Islam M and Shiffman J for The Lancet’s Stillbirth Series Steering Committee.

Stillbirths 1: Why they matter. Lancet 2011 Lawn JE, Blencowe H, Pattinson RC, Cousens S, Kumar R, Ibiebele I, Gardosi JO, Day LT and Stanton C for The Lancet’s Stillbirth Series Steering

Committee.

Stillbirths 2: Where? When? Why? How to make data count? Lancet 2011

Bhutta ZA, Yakoob MY, Lawn JE, Rizvi A, Friberg I, Weissman E, Buchman E and Goldenberg RL for The Lancet’s Series Steering Committee.

Stillbirths 3: What works? How much difference can we make and at what cost? Lancet 2011 Pattinson RC, Kerber K, Buchmann E, Friberg I, Belizan M, Lansky S, Weissman E, Mathai M, Rudan I and Walker N for The Lancet’s Series Steering

Committee.

Stillbirths 4: How can health systems deliver for mothers and babies? Lancet 2011 Flenady V, Middleton P, Smith GCC, Duke CW, Erwich JJ, Khong TY, Neilson JP, Ezzati M, Koopmans L, Ellwood D, Fretts RC and Frøen JF for The

Lancet’s Series Steering Committee.

Stillbirths 5: The way forward in high income countries. Lancet 2011 Goldenberg RL, McClure EM, Bhutta ZA, Belizan JM, Reddy UM, Mbebya H, Flenady V and Darmstadt GL for The Lancet’s Stillbirth Series Steering

Committee.

Stillbirths 6: The vision for 2020. Lancet 2011

Cousens S, Stanton C, Blencowe H, Ahmed S, Steinhardt L, Creanga A, Tuncalp O, Patel Z, Gupta S, Say L, Lawn JE.

National, regional and global estimates of stillbirth rates in 2008 with trends since 1995. Lancet 2011

Flenady V, Koopmans L, Middleton P, Frøen JF, Smith GCC, Gibbons K, Coory M, Gordon A, Ellwood D, McIntyre HD, Fretts RC, Ezzati M.

Stillbirth prevention in high income countries: the potential of addressing major risk factors. Lancet 2011


1. Invisibility of stillbirth: Why stillbirth matters

2. Information to making stillbirths count: Where? When? Why?

3. Interventions: Evidence on what works

4. Implementation: Integrated care has triple benefit

5. High-income settings: Priority actions

6. 2020 vision: Goals and research priorities

All papers can be accessed free at www.lancet.com/series/stillbirth

http://www.lancet.com/series/stillbirth

Research articles (2)

Stillbirth rate estimate and trends for 193 countries

Risk factors for stillbirth in high income countries

Commentaries (8) Lancet editors

Parent’s perspective

Professionals perspective and commitment

Including stillbirths in family health

Stillbirth estimates

Stillbirth risk factors

Inequalities in stillbirth

Stillbirth and reproductive rights




Paper 1: Stillbirths: Why they matter Invisibility from individual baby to global health agenda

Source: Frøen JF, Cacciatore J, McClure EM, et al, for The Lancet’s

Stillbirths Series steering committee. Stillbirths: why they matter. Lancet

2011; published online April 14. DOI:10.1016/S0140-6736(10)62232-5.

Review of scientific literature and key

global health policy documents by

United Nations agencies

Survey of 2427 health professionals in

136 countries on perceptions of

stillbirths in their community –

recruited by professional

associations

Survey of 937 affected parents, mostly

high income countries – recruited by

parental associations in ISA

Paper 1: Stillbirths: Why they matter Invisibility from individual baby to global health agenda

Source: Frøen JF, Cacciatore J, McClure EM, et al, for The Lancet’s

Stillbirths Series steering committee. Stillbirths: why they matter. Lancet

2011; published online April 14. DOI:10.1016/S0140-6736(10)62232-5.

Invisibility of the event and the

individual baby

Stigma and marginalization of

the mother in communities

Invisibility of numbers and

medical causes

Widespread fatalism regarding

prevention opportunities

Lacking national and

international leadership

Stillbirths don’t count …

1. Global data NOT routinely reported to World Health Organisation

NOT included in the Global Burden of Disease metrics

NOT measured appropriately in most national surveys

NOT mentioned among any donor pledges for MCH to the UN DG 2010

2. Global goals NOT counted in the MDGs although intimately linked to:

– Maternal health in MDG 5

– Neonatal deaths, accounting for 41% of child deaths in MDG4

– Poverty (MDG 1) and girls education (MDG2)



Paper 2: Counting stillbirths

What is new?

• New estimates of stillbirth rate for 193 countries

– Increased input data, better modeling: vital registration or national stillbirth

registries, national household surveys, and studies identified through systematic searches.

– Time trends from 1995 to 2009

• New estimates of intrapartum stillbirths (during labor)

• Comparing causes of stillbirths

• Recommendations to improve and use data, plus research

priorities ranking by experts

Sources:

Cousens S, Stanton C, Blencowe H, et al. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis.

Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(10)62310-0.

Lawn JE, Blencowe H, Pattinson R, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: Where? When? Why? How to make the data

count? Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(10)62187-3.

Country variation in stillbirth rates

10 countries account for 66% of

the world’s stillbirths

and 66% of neonatal

deaths and 60% of

maternal deaths

1. India

2. Pakistan

3. Nigeria

4. China

5. Bangladesh

6. Dem Rep Congo

7. Ethiopia

8. Indonesia

9. Tanzania

10. Afghanistan

Stillbirth rates (deaths per 1000 livebirths)

Lowest rates

Finland (2)

Singapore (2)

Highest rates

192. Nigeria (42)

193. Pakistan (47)

2.6 (2.1 to 3.8) million stillbirths

98% occur in low-income and middle-income countries

Stillbirths during labor – 1.2 million a year

The risk of stillbirth during labor (intrapartum) for an African woman is 50 times

higher than for a woman in the UK.

55% of all stillbirths are for rural families in Africa, South Asia

Causes of stillbirths

Estimates for stillbirth are impeded by more than 35 different

classification systems

The “big five” causes:

1. Childbirth complications

2. Maternal infections in pregnancy e.g. syphilis

3. Maternal conditions, especially hypertension and diabetes

4. Fetal growth restriction (placental insufficiencies)

5. Congenital abnormalities

These overlap with the causes of maternal and neonatal deaths

The causes in H/MIC:

1. Placenta 29%

2. Infections 12%

3. Cord complications 9%

4. Maternal conditions 7%

5. Congenital anomalies 6%

6. Fetal conditions 4%

7. Intrapartum events 3%

8. Unexplained 5%

(Unknown 30%)

Paper 3 and 4:

Interventions and Implementation

What is new?

• Systematic reviews for interventions with effect on stillbirth

– Effect of 35 interventions reviewed,10 interventions selected

• Lives Saved Tool (LiST) and cost modelling

– How many stillbirths could be prevented in 68 Priority countries?

– How many mothers and newborns would also be saved?

– Which interventions have the most effect and may be more feasible in low income settings?

– Running cost per year of the interventions

• Implementation priorities and integration of services

• Research priorities ranked for intervention and implementation

Sources:

Pattinson R, Kerber K, Buchmann E, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: how can health systems deliver for mothers and

babies? Lancet 2011; published online April 14. DOI:10.1016/S0140-6736(10)62306-9.

Bhutta ZA, Yakoob MY, Lawn JE, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: what difference can we make and at what cost?


10 evidence-based interventions

Interventions considered in the model 99% coverage

Stillbirths Reduction

1 Periconceptual folic acid fortification 27,000 1%

2 Malaria in pregnancy - ITNs & IPTp 35,000 1%

3 Syphilis screening and treatment 136,000 5%

4 Hypertensive diseases in pregnancy and management 57000 2%

5 Diabetes screening and management 24,000 1%

6 Fetal growth restriction management 107,000 4%

7 Induction of labor at or beyond 41 completed weeks 52,000 2%

8,9,10 Obstetric Care (3 levels of care) 696,000 28%

Total Stillbirths Averted 1,134,000 45%

Preventing maternal and neonatal deaths and stillbirths

Deaths prevented: Stillbirths 1.1 million (45%)

Newborn deaths 1.1 (44%)

Maternal deaths 201,000 (54%)

Highly cost effective

• Childbirth care cost analysis

• Cost per maternal death prevented is US$54,350

• Counting newborns and stillbirths this becomes $3,920 per death prevented

• Total additional running cost of US$ 10.9 billion for the 68 priority countries per year for full coverage of care with

• 10 interventions for women, newborns and stillbirths

• plus 5 maternal and newborn specific interventions

US $ 2.32 per year per person in the 68 priority countries

Paper 5: High income countries

What is new?

• Stillbirth data and time trends from 13 countries

• Causes and maternal conditions using a comparable

classification system

• Risk factors analysis

– Systematic review of studies addressing life style risk factors including

obesity, advanced maternal age and smoking

• Research priorities ranking by experts

Source: Flenady V, Middleton P, Smith GC, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: the way forward in high-income countries.


Paper 6: Stillbirths: the vision for 2020

Source: Goldenberg RL, McClure EM, Bhutta ZA, et al, for The Lancet’s Stillbirths Series steering committee. Stillbirths: the vision for 2020. Lancet 2011;

published online April 14. DOI:10.1016/S0140-6736(10)62235-0.

Woods R. Long-term trends in fetal mortality: implications for developing countries. Bull WHO 2008; 86: 460-6.

Stillbirth rates halved 1950-1975 with improvements in infection treatment and obstetric care

– feasible now and linked to reductions in maternal and neonatal mortality

Goal by 2020

• Countries with a current stillbirth rate of less

than 5 per 1000 births, the goal by 2020 is

to eliminate all preventable stillbirths and close

equity gaps.

• Countries with a current stillbirth rate of more

than 5 per 1000 births to reduce their stillbirth

rates by at least 50% from the 2008 rates.


PM

NC

H

Sands U

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Individual countries

• Create a plan for stillbirth reduction

• Collect accurate data on stillbirth rates and

causes of death

• Assess disparities in stillbirth rates by ethnic

origin and location

• Audit stillbirths for causes and preventability

• Reduce stigma associated with stillbirth

Sands U

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An initiative to harmonize Reproductive Health Registries

J. Frederik Frøen, MD, dr.med, dr.philos

Director, Dept. of Genes and Environment

Norwegian Institute of Public Health

Sources of quantitative data – issues of quality

Census

Surveys

Registries

Vital registration systems (complete or samples)

Disease registries

Hybrids

Administrative records (tax,

schooling, phone etc)

Coverage (sampling)

Completeness (non-response)

Comparability (time, space, method

of enumeration)

Validity (correct?)

Timeliness

Usefullness

Large knowledge gaps about the status of world health – even core indicators of MDG 4 & 5 are estimates, not data

Implications

Visibility and priority

Governance

Planning and delivery of health care

Planning of public health services

Monitoring and evaluation

Human rights

Evidence-based policies

Research

Health registries

Unselected and unbiased – equitable when 100 % are included

Many diseases, treatments and risk factors evaluated simultaneously

Safe and gentle for participants

Protection of privacy

Can secure individual rights

Cost effective and accountable

Basis for other research

Possibility for longterm follow-up

Big numbers and powerful results

Reality-based – when RCTs are impossible

Randomized & controlled implementation and scale-up

Reproductive health vs ANC, birth & death registries? Quality of care, maternal & neonatal deaths & stillbirths

Deaths prevented: (at 99% coverage)

Stillbirths 1.1 million (45%)

Newborn deaths 1.1 (44%)

Maternal deaths 201,000 (54%)

Cost at 100% coverage: (in 68 MDG priority countries)

US $ 2.32 per year per person

•“The missing denominator”

• Maternal deaths

• Neonatal deaths

• Stillbirths

• Terminations

•Prospective data collection (vs. reporting of adverse events)

•Antenatal & postpartum care (vs. “pure” obstetrics’ focus)

•Monitoring and evaluation

JF Frøen, JE Lawn, Z Bhutta, RC Pattinson, V Flenady, RL Goldenberg and M Islam

Evidence-based care and interventions Global and national guidelines

Targets for surveillance & monitoring

VR + hRHR module Module-based data sets of pregnancy, birth, maternity,

infancy, ICD-MM & -PM

Technical solutions and databases Interactive check-lists and suppport

Open source e & mHealth Data collection methodologies

Surveillance & evaluation Audit and feedback

Training & capacity building Dissemination and cooperation

Ethical, legal & societal impact Framework for surveillance,

research, development and accountability

hRHR

Harmonized Reproductive Health Registries

the lancet’s stillbirth series - gyn bethlehem 2012 · 2012-03-15 · • monir islam (in / who)...

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