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Stillbirth
Other namesFetal death, fetal demise[1]
Ultrasound is often used to diagnose stillbirth and medical conditions that raise the risk.
SpecialtyObstetrics and Gynaecology, neonatology, pediatrics,
SymptomsFetal death at or after 20 / 28 weeks of pregnancy[1][2]: Overview tab 
CausesOften unknown, pregnancy complications[1][3]
Risk factorsMother's age over 35, smoking, drug use, use of assisted reproductive technology[4]
Diagnostic methodNo fetal movement felt, ultrasound[5]
TreatmentInduction of labor, dilation and evacuation[6]
Frequency1.9 million (1 for every 72 total births)[7]

Stillbirth is typically defined as the death of a fetus at or after 20 or 28 weeks of pregnancy, depending on the source.[1][2]: Overview tab, [8] It results in a baby born without signs of life.[9] A stillbirth can often result in the feeling of guilt or grief in the mother.[10] The term is in contrast to miscarriage, which is an early pregnancy loss,[11] and sudden infant death syndrome, where the baby dies a short time after being born alive.[10]

Often the cause is unknown.[1][12] Causes may include pregnancy complications such as pre-eclampsia and birth complications, problems with the placenta or umbilical cord, birth defects, infections such as malaria and syphilis, and poor health in the mother.[2]: Causes tab, [3][13] Risk factors include a mother's age over 35, smoking, drug use, use of assisted reproductive technology, and first pregnancy.[4] Stillbirth may be suspected when no fetal movement is felt.[5] Confirmation is by ultrasound.[5]

Worldwide prevention of most stillbirths is possible with improved health systems.[2]: Overview tab, [14] Around half of stillbirths occur during childbirth, with this being more common in the developing than developed world.[2]: Info panel,  Otherwise, depending on how far along the pregnancy is, medications may be used to start labor or a type of surgery known as dilation and evacuation may be carried out.[6] Following a stillbirth, women are at higher risk of another one; however, most subsequent pregnancies do not have similar problems.[15] Depression, financial loss, and family breakdown are known complications.[14]

Worldwide in 2021, there were an estimated 1.9 million stillbirths that occurred after 28 weeks of pregnancy (about 1 for every 72 births).[16] More than three-quarters of estimated stillbirths in 2021 occurred in sub-Saharan Africa and South Asia, with 47% of the global total in sub-Saharan Africa and 32% in South Asia.[17] Stillbirth rates have declined, though more slowly since the 2000s.[18] According to UNICEF, the total number of stillbirths declined by 35%, from 2.9 million in 2000 to 1.9 million in 2021.[16] It is estimated that if the stillbirth rate for each country stays at the 2021 level, 17.5 million babies will be stillborn by 2030.[16]

Causes

[edit]

As of 2016, there is no international classification system for stillbirth causes.[19] The causes of a large percentage of stillbirths is unknown, even in cases where extensive testing and an autopsy have been performed. A rarely used term to describe these is "sudden antenatal death syndrome", or SADS, a phrase coined in 2000.[20] Many stillbirths occur at full term to apparently healthy pregnant women, and a postmortem evaluation reveals a cause of death in about 40% of autopsied cases.[21]

About 10% of cases are believed to be due to obesity, high blood pressure, or diabetes.[22]

Other risk factors include:

Entanglement of cord in twin pregnancy at the time of Caesarean section
  • umbilical cord accidents
    • Prolapsed umbilical cord – Prolapse of the umbilical cord happens when the fetus is not in a correct position in the pelvis. Membranes rupture and the cord is pushed out through the cervix. When the fetus pushes on the cervix, the cord is compressed and blocks blood and oxygen flow to the fetus. The pregnant woman has approximately 10 minutes to get to a doctor before there is any harm done to the fetus.
    • Monoamniotic twins – These twins share the same placenta and the same amniotic sac and therefore can interfere with each other's umbilical cords. When entanglement of the cords is detected, it is highly recommended to deliver the fetuses as early as 31 weeks.
    • Umbilical cord length – A short umbilical cord (<30 cm) can affect the fetus in that fetal movements can cause cord compression, constriction, and rupture. A long umbilical cord (>72 cm) can affect the fetus depending on the way the fetus interacts with the cord.[26] Some fetuses grasp the umbilical cord but it is yet unknown as to whether a fetus is strong enough to compress and stop blood flow through the cord. Also, an active fetus, one that frequently repositions itself in the uterus can accidentally entangle itself with the cord. A hyperactive fetus should be evaluated with ultrasound to rule out cord entanglement.
    • Cord entanglement – The umbilical cord can wrap around an extremity, the body or the neck of the fetus. When the cord is wrapped around the neck of the fetus, it is called a nuchal cord. These entanglements can cause constriction of blood flow to the fetus. These entanglements can be visualized with ultrasound.
    • Torsion – This term refers to the twisting of the umbilical around itself. Torsion of the umbilical cord is very common (especially in equine stillbirths) but it is not a natural state of the umbilical cord. The umbilical cord can be untwisted at delivery. The average cord has three twists.
  • Smoke inhalation – If a pregnant woman gets trapped in a building fire, the smoke and fumes can kill a fetus.[citation needed]

A pregnant woman sleeping on her back after 28 weeks of pregnancy may be a risk factor for stillbirth.[22][27]

After a stillbirth there is a 2.5% risk of another stillbirth in the next pregnancy (an increase from 0.4%).[28]

In the United States, highest rates of stillbirths happen in pregnant women who:[29]

  • are of low socioeconomic status
  • are aged 35 years or older
  • have chronic medical conditions such as diabetes, high blood pressure, high cholesterol, etc.
  • are African-American
  • have previously lost a pregnancy
  • have multiple children at a time (twins, triplets, etc.)

Diagnosis

[edit]

It is unknown how much time is needed for a fetus to die. Fetal behavior is consistent and a change in the fetus' movements or sleep-wake cycles can indicate fetal distress.[30] A decrease or cessation in sensations of fetal activity may be an indication of fetal distress or death,[31][32] Still, medical examination, including a nonstress test, is recommended in the event of any type of any change in the strength or frequency of fetal movement, especially a complete cease; most midwives and obstetricians recommend the use of a kick chart to assist in detecting any changes.[33] Fetal distress or death can be confirmed or ruled out via fetoscopy/doptone, ultrasound, and/or electronic fetal monitoring.[34] If the fetus is alive but inactive, extra attention will be given to the placenta and umbilical cord during ultrasound examination to ensure that there is no compromise of oxygen and nutrient delivery.[35]

Some researchers have tried to develop models to identify, early on, pregnant women who may be at high risk of having a stillbirth.[36]

Definition

[edit]

There are a number of definitions for stillbirth.[37] To allow comparison, the World Health Organization uses the ICD-10 definitions and recommends that any baby born without signs of life at greater than or equal to 28 completed weeks' gestation be classified as a stillbirth.[2]: Overview tab  The WHO uses the ICD-10 definitions of "late fetal deaths" as their definition of stillbirth.[18] Other organisations recommend that any combination of greater than 16, 20, 22, 24 or 28 weeks gestational age or 350 g, 400 g, 500 g or 1000 g birth weight may be considered a stillbirth.[38]

The term is often used in distinction to live birth (the baby was born alive, even if they died shortly thereafter) or miscarriage (early pregnancy loss[37]). The word miscarriage is often used incorrectly to describe stillbirths.[37] The term is mostly used in a human context; however, the same phenomenon can occur in all species of placental mammals.

Constricted umbilical cord

[edit]

When the umbilical cord is constricted (q.v. "accidents" above), the fetus experiences periods of hypoxia, and may respond by unusually high periods of kicking or struggling, to free the umbilical cord.[39] These are sporadic if constriction is due to a change in the fetus' or mother's position, and may become worse or more frequent as the fetus grows.[40] Extra attention should be given if mothers experience large increases in kicking from previous childbirths, especially when increases correspond to position changes.[41]

Regulating high blood pressure, diabetes and drug use may reduce the risk of a stillbirth. Umbilical cord constriction may be identified and observed by ultrasound, if requested.[42]

Some maternal factors are associated with stillbirth, including being age 35 or older, having diabetes, having a history of addiction to illegal drugs, being overweight or obese, and smoking cigarettes in the three months before getting pregnant.[43]

Treatment

[edit]
A cuddle cot

Fetal death in utero does not present an immediate health risk to the pregnant woman, and labour will usually begin spontaneously after two weeks, so the pregnant woman may choose to wait and bear the fetal remains vaginally.[44] After two weeks, the pregnant woman is at risk of developing blood clotting problems, and labor induction is recommended at this point.[45] In many cases, the pregnant woman will find the idea of carrying the dead fetus traumatizing and will elect to have labor induced. Caesarean birth is not recommended unless complications develop during vaginal birth.[46] How the diagnosis of stillbirth is communicated by healthcare workers may have a long-lasting and deep impact on parents.[47] People need to heal physically after a stillbirth just as they do emotionally. In Ireland, for example, people are offered a 'cuddle cot', a cooled cot which allows them to spend a number of days with their child before burial or cremation.[48]

Delivery

[edit]

In single stillbirths, common practice is to induce labor for the health of the mother due to possible complications such as exsanguination. Induction and labor can take 48 hours.[37] In the case of various complications such as preclampsia, infections, multiples (twins), emergency Cesarean may occur.[49]

Epidemiology

[edit]
Stillbirth rate

The average stillbirth rate in the United States is approximately 1 in 160 births, which is roughly 26,000 stillbirths each year.[50] In Australia,[51] England, Wales,[52][53] and Northern Ireland,[54] the rate is approximately 1 in every 200 births; in Scotland, 1 in 167.[55] Rates of stillbirth in the United States have decreased by about two-thirds since the 1950s.[56]

The vast majority of stillbirths worldwide (98%) occur in low- and middle-income countries, where medical care can be of low quality or unavailable. Reliable estimates calculate that, yearly, about 2.6 million stillbirths occur worldwide during the third trimester.[13] Stillbirths were previously not included in the Global Burden of Disease Study which records worldwide deaths from various causes until 2015.[57]

Society and culture

[edit]

The way people view stillbirths has changed dramatically over time; however, its economic and psychosocial impact is often underestimated.[58] In the early 20th century, when a stillbirth occurred, the baby was taken and discarded and the parents were expected to immediately let go of the attachment and try for another baby.[59][page needed] In many countries, parents are expected by friends and family members to recover from the loss of an unborn baby very soon after it happens.[21] Societally-mediated complications such as financial hardship and depression are among the more common results.[21] A stillbirth can have significant psychological effects on the parents, notably causing feelings of guilt in the mother.[10] Further psycho-social effects on parents include apprehension, anger, feelings of worthlessness and not wanting to interact with other people, with these reactions sometimes carried over into pregnancies that occur after the stillbirth.[60] Men also suffer psychologically after stillbirth, although they are more likely to hide their grief and feelings and try to act strong, with the focus on supporting their partner.[61]

[edit]
In Japan, statues of Jizō, a Buddhist patron deity of children, memorialize stillborn babies.

Australia

[edit]

In Australia, stillbirth is defined as a baby born with no signs of life that weighs more than 400 grams, or more than 20 weeks in gestation. They legally must have their birth registered.[62]

Austria

[edit]

In Austria, a stillbirth is defined as a birth of a child of at least 500g weight without vital signs, e.g. blood circulation, breath or muscle movements.[63]

Canada

[edit]

Beginning in 1959, "the definition of a stillbirth was revised to conform, in substance, to the definition of fetal death recommended by the World Health Organization".[64] The definition of "fetal death" promulgated by the World Health Organization in 1950 is as follows:

"Fetal death" means death prior to the complete expulsion or extraction from its mother of a product of human conception, irrespective of the duration of pregnancy and which is not an induced termination of pregnancy.[63] The death is indicated by the fact that after such expulsion or extraction, the fetus does not breathe or show any other evidence of life, such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles.[44] Heartbeats are to be distinguished from transient cardiac contractions; respirations are to be distinguished from fleeting respiratory efforts or gasps.[65]

Germany

[edit]
Monument to stillborn babies in Germany

In Germany, a stillbirth is defined as the birth of a child of at least 500g weight without blood circulation or breath. Details for burial vary amongst the federal states.[66]

Ireland

[edit]
At one time, this Angels' Plot was one of the few burial grounds for stillborn babies that was consecrated by the Catholic Church in Ireland.

Since 1 January 1995, stillbirths occurring in Ireland must be registered; stillbirths that occurred before that date can also be registered but evidence is required.[67] For the purposes of civil registration, s.1 of the Stillbirths Registration Act 1994 refers to "...a child weighing at least 500 grammes, or having reached a gestational age of at least 24 weeks who shows no signs of life."

Netherlands

[edit]

In the Netherlands, stillbirth is defined differently by the Central Bureau of Statistics (CBS) and the Dutch Perinatal Registry (Stichting PRN[68]). The birth and mortality numbers from the CBS include all livebirths, regardless of gestational duration, and all stillbirths from 24 weeks of gestation and onwards.[69] In the Perinatal Registry, gestational duration of both liveborn and stillborn children is available.[70] They register all liveborn and stillborn children from 22, 24 or 28 weeks of gestation and onwards (dependent on the report: fetal, neonatal or perinatal mortality).[71] Therefore, data from these institutions on (still)births cannot be compared simply one-on-one.

United Kingdom

[edit]

The registration of stillbirths has been required in England and Wales from 1927 and in Scotland from 1939 but is not required in Northern Ireland.[72] Sometimes a pregnancy is terminated deliberately during a late phase, for example due to congenital anomaly.[73] UK law requires these procedures to be registered as "stillbirths".[74]

England and Wales
[edit]

For the purposes of the Births and Deaths Registration Act 1926 (as amended), section 12 contains the definition:

"still-born" and "still-birth" shall apply to any child which has issued forth from its mother after the twenty fourth week of pregnancy and which did not at any time after being completely expelled from its mother, breathe or show any other signs of life.

A similar definition is applied within the Births and Deaths Registration Act 1953 (as amended), contained in s.41.

The above definitions apply within those Acts thus other legislation will not necessarily be in identical terms.

s.2 of the 1953 Act requires that registration of a birth takes place within 42 days of the birth except where an inquest takes place or the child has been "found exposed" in which latter case the time limit runs from the time of finding.

Extracts from the register of stillbirths are restricted to those who have obtained consent from the Registrar General for England and Wales.[75]

Scotland
[edit]

Section 56(1) of the Registration of Births, Deaths and Marriages (Scotland) Act 1965 (as amended) contains the definition:

"still-born child" means a child which has issued forth from its mother after the twenty-fourth week of pregnancy and which did not at any time after being completely expelled from its mother breathe or show any other signs of life, and the expression "still-birth" shall be construed accordingly

s.21(1) of the same Act requires that:

Except so far as otherwise provided by this section or as may be prescribed, the provisions of this Part of this Act shall, so far as applicable, apply to still-births in like manner as they apply to births of children born alive.

In the general case, s.14 of the Act requires that a birth has to be registered within 21 days of the birth or of the child being found.

Unlike the registers for births, marriages, civil partnerships and deaths, the register of still-births is not open to public access and issue of extracts requires the permission of the Registrar General for Scotland.[76]

Northern Ireland
[edit]

In Northern Ireland, the Births and Deaths Registration (Northern Ireland) Order 1976,[77] as amended contains the definition:

"still-birth" means the complete expulsion or extraction from its mother after the twenty-fourth week of pregnancy of a child which did not at any time after being completely expelled or extracted breathe or show any other evidence of life.

Registration of stillbirths can be made by a relative or certain other persons involved with the stillbirth but it is not compulsory to do so.[78] Registration takes place with the District Registrar for the Registration District where the still-birth occurred or for the District in which the mother is resident.[79] A stillbirth certificate will be issued to the registrant with further copies only available to those obtaining official consent for their issue.[80] Registration may be made within three months of the still-birth.[72]

United States

[edit]

In the United States, there is no standard definition of the term 'stillbirth'.[65]

In the U.S., the Born-Alive Infants Protection Act of 2002 specifies that any breathing, heartbeat, pulsating umbilical cord or confirmed voluntary muscle movement indicate live birth rather than stillbirth.[81]

The Centers for Disease Control and Prevention collects statistical information on "live births, fetal deaths, and induced termination of pregnancy" from 57 reporting areas in the United States.[82] Each reporting area has different guidelines and definitions for what is being reported; many do not use the term "stillbirth" at all.[37] The federal guidelines suggest (at page 1) that fetal death and stillbirth can be interchangeable terms. The CDC definition of "fetal death" is based on the definition promulgated by the World Health Organization in 1950 (see section above on Canada).[83] Researchers are learning more about the long term psychiatric sequelae of traumatic birth and believe the effects may be intergenerational[84]

The CDC states that, in the US, a stillbirth is typically defined as the loss of a fetus during or after the 20th week of pregnancy. Stillbirths can further be classified as early (occurring between week 20 and week 27 of pregnancy), late (occurring between week 28 and week 36 of pregnancy), and term (occurring during or after week 37 of pregnancy). In the US, approximately 21,000 babies are stillborn annually, and stillbirth affects around 1 in 175 births.[85]

The federal guidelines recommend reporting those fetal deaths whose birth weight is over 12.5 oz (350 g), or those more than 20 weeks gestation.[63] Forty-one areas use a definition very similar to the federal definition, thirteen areas use a shortened definition of fetal death, and three areas have no formal definition of fetal death. Only 11 areas specifically use the term 'stillbirth', often synonymously with late fetal death; however, they are split between whether stillbirths are "irrespective of the duration of pregnancy", or whether some age or weight constraint is applied. A movement in the U.S.[63] has changed the way that stillbirths are documented through vital records. Previously, only the deaths were reported. However, 27 states have enacted legislation that offers some variation of a birth certificate as an option for parents who choose to pay for one.[86] Parents may not claim a tax exemption for stillborn infants, even if a birth certificate is offered. To claim an exemption, the birth must be certified as live, even if the infant only lives for a very brief period.[87]

After Dobbs v. Jackson Women's Health Organization, some states restricted women's access to abortion, even when the pregnancy is nonviable.[88] Legal restrictions on medications and procedures that have been used for abortions may also impact treatment options for women undergoing a miscarriage or stillbirth.[89]

See also

[edit]

References

[edit]
[edit]
Revisions and contributorsEdit on WikipediaRead on Wikipedia

Stillbirth

View on Grokipedia
from Grokipedia
Stillbirth is the death of a fetus in utero at or after 28 completed weeks of gestational age, with no signs of life at delivery, as defined by the World Health Organization for international comparability. This excludes earlier fetal losses classified as miscarriages and encompasses antepartum deaths (before labor onset) and intrapartum deaths (during labor). Globally, stillbirths represent a major contributor to perinatal mortality, often undercounted in low-resource settings due to inconsistent reporting standards.30055-5/fulltext) In 2021, an estimated 1.9 million stillbirths occurred worldwide after 28 weeks' , yielding a global rate of 13.9 stillbirths per 1,000 total births, equivalent to one every 16 seconds. Rates vary starkly by region, with high-income countries experiencing 2-3 per 1,000 births compared to over 20 per 1,000 in parts of and , where limited access to antenatal monitoring exacerbates outcomes. , approximately 21,000 stillbirths occur annually, at a rate of about 5.8 per 1,000 births using a 20-week threshold, though adjusted global alignments highlight persistent disparities linked to socioeconomic and factors. Over 40% of stillbirths happen during labor in under-resourced areas, underscoring opportunities for intervention through improved obstetric care. The of stillbirth frequently involves placental dysfunction, such as insufficiency or abruption, which compromises fetal oxygenation and nutrient supply, alongside complications like or entanglement. Other established causes include fetal (18-37% of cases), congenital anomalies, and intrauterine infections, with maternal contributors like hypertensive disorders, , , and elevating risk through direct physiological impacts.00180-2/fulltext) In up to 25-60% of cases, no definitive cause is identified post-examination, though autopsies and placental reveal preventable elements like fetal growth restriction in many instances. Risk factors compound causally, with , pregestational , multiple gestation, and short interpregnancy intervals independently increasing odds, often via impaired vascular or metabolic pathways.00436-9/fulltext) Prevention hinges on addressing modifiable elements, such as and glycemic control, which demonstrably lower incidence in population studies.

Definition and Classification

Gestational Thresholds and Clinical Criteria

Stillbirth is defined as the death of a fetus in utero at or after a specified gestational age or fetal weight threshold, distinguishing it from earlier pregnancy losses classified as miscarriages. The gestational age threshold varies by jurisdiction and reporting standards, commonly ranging from 20 to 28 weeks, with corresponding fetal weight equivalents of approximately 350–500 grams to account for cases where precise dating is unavailable. These criteria facilitate consistent epidemiological tracking, legal registration, and clinical management, though inconsistencies arise due to differences in ultrasound dating accuracy, cultural practices, and data collection priorities. In the United States, the Centers for Disease Control and Prevention (CDC) establishes the threshold at 20 weeks of gestation or a of at least 350 grams for fetal death reporting, aligning with guidelines from the American College of Obstetricians and Gynecologists (ACOG). This cutoff reflects the viability considerations post-Roe v. Wade legal frameworks and emphasizes comprehensive vital statistics collection, where stillbirths after 20 weeks represent about 1 in 175 pregnancies. Internationally, the (WHO) and (ICD) recommend a threshold of 22 weeks of gestation or 500 grams to standardize global comparisons, as lower thresholds may inflate rates in regions with variable access. Clinical diagnosis requires objective confirmation of fetal demise, primarily through real-time ultrasonography demonstrating absent cardiac activity, as auscultation of fetal heart tones via Doppler or fetoscope can yield false negatives due to positioning or equipment limitations. Supplementary assessments may include serial ultrasounds to rule out transient , though persistent absence of heartbeat beyond 30 minutes is diagnostic. In resource-limited settings, where is unavailable, criteria may rely on maternal perception of absent fetal movements combined with historical gestational dating, but this increases diagnostic uncertainty. or postmortem imaging can corroborate findings but is not required for initial . Variations in thresholds persist globally; for instance, many European nations adopt 24 weeks to align with neonatal viability data, while some low-income countries use 28 weeks for stillbirth reporting to focus on late-term losses amenable to intervention. These discrepancies complicate cross-national comparisons, with studies estimating that harmonizing to a 20-week threshold could reveal up to 30% more cases worldwide.

Global and National Variations

The (WHO) establishes a standardized threshold for international stillbirth reporting as a fetal death after 28 completed weeks of or with a birthweight of at least 1000 grams, aiming to ensure comparability across diverse health systems. This late- focus aligns with UNICEF data, which tracks stillbirth rates from 28 weeks onward, estimating a global rate of 14.3 per 1000 total births in recent years. However, adoption of this threshold varies, particularly in low- and middle-income countries where registration may prioritize later losses due to limited antenatal monitoring, potentially underreporting earlier events.01925-1/fulltext) High-income countries frequently employ lower gestational age cutoffs, capturing a broader range of fetal deaths and yielding higher reported rates. In the United States, the Centers for Disease Control and Prevention (CDC) defines stillbirth as fetal death at 20 weeks gestation or later, or with a birthweight of 350 grams or more, facilitating comprehensive surveillance of approximately 21,000 annual cases. The United Kingdom uses a 24-week threshold, classifying a stillborn infant as one delivered without signs of life after this point, consistent with National Health Service guidelines and Royal College of Obstetricians and Gynaecologists protocols. Australia and Canada similarly set the bar at 20 weeks or a birthweight of 400 grams, reflecting advanced diagnostic capabilities for earlier gestations. European nations exhibit further heterogeneity, with many registering stillbirths from 22 or 24 weeks or a minimum birthweight of 500 grams, though practices differ by country— for example, some Scandinavian registries include losses as early as 16-20 weeks for research purposes. These discrepancies complicate cross-national comparisons, as lower thresholds in high-resource settings inflate rates relative to WHO-aligned data; studies adjusting for a uniform 20-week cutoff estimate global stillbirths at 23.0 per 1000 births in 2021, versus lower figures under 28-week standards.01925-1/fulltext) Birthweight-based criteria (e.g., 500-1000 grams) serve as alternatives where gestational dating is unreliable, but they correlate imperfectly with age, exacerbating inconsistencies in global burden assessments. Efforts to harmonize definitions, such as those in the Global Burden of Disease studies, underscore the need for standardized vital registration to accurately track progress toward reduction targets.01925-1/fulltext)

Epidemiology

Global and Regional Incidence Rates

The global stillbirth rate, defined as fetal deaths at 28 weeks of or later per 1,000 total births (live births plus stillbirths), stood at 14.3 in 2023, equating to approximately 1.9 million stillbirths worldwide, or one every 40 seconds. This rate reflects a modest decline from 13.9 in 2021, though progress has stalled in recent years, with over 40% of cases occurring during labor in settings lacking adequate monitoring. When including earlier gestations from 20 weeks onward, estimates rise to around 23 per 1,000 births as of 2021, highlighting definitional inconsistencies across studies that complicate direct comparisons.01925-1/fulltext) Regional disparities are stark, driven primarily by differences in healthcare access, maternal nutrition, and infection control rather than inherent biological factors. bears the heaviest burden, with a 2023 rate of 22.2 per 1,000 total births—7.9 times higher than in and —and accounting for nearly 48% of global stillbirths despite comprising about 17% of worldwide births. Within this region, West and Central Africa report the highest subregional rates, exceeding 25 per 1,000 in some estimates from 2019 data, followed closely by Eastern and Southern Africa. In Central and Southern Asia, rates hover around 12-15 per 1,000, reflecting improvements from and but persistent challenges from and . High-income regions exhibit rates below 3 per 1,000; for instance, recorded about 5.7 per 1,000 (or 1 in 175 pregnancies) in recent U.S. data, while maintains levels near 2.5, attributable to routine antenatal care and rapid intervention capabilities. Country-level variations further underscore this gradient, with low rates in nations like (4 per 1,000) contrasting sharply with highs in (28 per 1,000) as of 2023 estimates.
RegionStillbirth Rate (per 1,000 total births, latest available)Share of Global Stillbirths
22.2 (2023)~48% (2023)
Central/Southern Asia~13 (2021-2023 estimates)~25%
Europe/N. America~2.8 (2023)<5%
Global14.3 (2023)100%
These figures, derived from vital registration, surveys, and modeling by bodies like the UN Inter-agency Group for Child Mortality Estimation, reveal that over 75% of stillbirths occur in just 10 countries, predominantly low- and middle-income, where underreporting may underestimate true incidence by 20-30% due to cultural taboos and weak surveillance.

Demographic Disparities and Risk Stratification

Stillbirth rates exhibit significant disparities across demographic groups, with non-Hispanic Black women in the United States experiencing rates approximately twice those of non-Hispanic White women. In recent data, the stillbirth rate among non-Hispanic Black mothers stands at 9.1 per 1,000 births, compared to 4.7 per 1,000 for non-Hispanic White mothers and 3.9 per 1,000 for non-Hispanic Asian mothers. Studies on Black-White interracial couples reveal a risk gradient: lowest for White mother-White father couples (reference), followed by White mother-Black father (adjusted OR ≈1.8), Black mother-White father (adjusted OR ≈2.0), and highest for Black mother-Black father (adjusted OR ≈2.1), with risks largely mediated by prematurity and low birth weight. Hispanic mothers show intermediate rates at 4.7 per 1,000. These differences persist after adjusting for factors like maternal education and persist across gestational ages, though causes such as maternal complications and diabetes contribute more prominently in Black populations. Globally, socioeconomic status correlates inversely with stillbirth incidence, with women in the lowest socioeconomic groups facing median rates of 4.9 per 1,000 total births versus lower rates in higher-status groups. Maternal age represents another key disparity, with risks escalating notably beyond 35 years and peaking in women aged 40 and older, who face a 40-50% higher likelihood of stillbirth compared to those aged 20-29. Nulliparity (first pregnancy) further amplifies this, as first-time mothers exhibit elevated risks independent of age. Socioeconomic gradients extend beyond income to include education and access to care; higher household income associates with reduced stillbirth risk, potentially through better management of modifiable factors. Geographic and regional variations compound these, with rural or low-resource settings showing higher rates due to delayed interventions.
Demographic GroupStillbirth Rate (per 1,000 births, US)
Non-Hispanic Black9.1
Non-Hispanic White4.7
Hispanic4.7
Non-Hispanic Asian3.9
Risk stratification integrates these demographic factors to prioritize antenatal monitoring and interventions. Non-Hispanic Black race, advanced maternal age (≥35 years), and low socioeconomic status serve as independent predictors, often combined in scoring systems to classify pregnancies as high-risk, prompting measures like increased fetal movement assessments or earlier delivery planning. For instance, Black women and those over 40 warrant closer surveillance due to elevated baseline risks, while nulliparity adds cumulative weight in models assessing overall probability. Such stratification, grounded in population-level data, enables targeted resource allocation without overgeneralizing individual cases, though structural factors like access disparities must be addressed to mitigate persistent inequities. Global stillbirth rates, defined as fetal deaths at or after 28 weeks of gestation per 1,000 total births, declined substantially from 21.4 in 2000 to 13.9 in 2019, reflecting a 35% reduction driven by improvements in antenatal care, infection control, and access to skilled birth attendance in low- and middle-income countries. This progress aligned with broader maternal and child health initiatives, including the United Nations' , which indirectly addressed stillbirth through reductions in preterm birth and intrapartum complications. In high-income countries, such as the United States, stillbirth rates have fallen dramatically since the 1940s due to advancements in prenatal screening, obstetric interventions, and public health measures like rubella vaccination and better nutrition, dropping from over 40 per 1,000 births in the mid-20th century to approximately 5.7 per 1,000 (for gestations of 20 weeks or more) in recent years, affecting about 21,000 cases annually. European trends from 2010 to 2020 show modest declines in most countries, with rates stabilizing around 2-4 per 1,000, though variations persist due to differences in reporting thresholds and maternal demographics. Recent developments indicate a slowdown in global reductions, with the annual rate of decline dropping 53% since 2015 compared to the 2000-2015 period, reaching 14.3 per 1,000 total births by 2023 amid disruptions from the , including reduced access to care and increased maternal stress. In the United States, rates rose slightly in 2020—the first year of widespread lockdowns—before stabilizing at nearly 6 per 1,000 in 2021, with no significant decline in late stillbirths (28 weeks or more) from 2019 levels. Progress toward the Every Newborn Action Plan's target of 12 or fewer stillbirths per 1,000 by 2030 remains off-track, particularly in regions with high burdens like , where rates exceed 20 per 1,000.

Etiology and Risk Factors

Fetal and Genetic Contributors

Chromosomal abnormalities are identified in 10-20% of stillbirth cases, representing a primary fetal genetic contributor. Common aneuploidies include trisomy 13 (Patau syndrome), trisomy 18 (Edwards syndrome), and triploidy, which often result in severe structural malformations incompatible with extrauterine life. These anomalies disrupt fetal development, leading to intrauterine demise typically in the second or third trimester. Karyotype analysis detects such abnormalities in 6-13% of evaluated stillbirths, though culture failure in postmortem tissues can underestimate prevalence. Congenital anomalies, frequently rooted in genetic etiologies, account for approximately 10% of stillbirths. Major structural defects such as neural tube defects, cardiac malformations, and renal agenesis correlate with chromosomal or monogenic disorders, increasing stillbirth risk independent of gestational age. For instance, fetuses with multiple anomalies exhibit higher demise rates due to impaired organ function and growth restriction. Autopsy reveals these in many cases, with genetic testing confirming underlying syndromes like those involving copy number variants. Beyond aneuploidy, monogenic variants and novel loss-of-function mutations explain an estimated 5.5% of stillbirths, often affecting placental or fetal developmental genes. Whole-exome sequencing in unexplained cases identifies causal variants in genes linked to cardiac channelopathies or metabolic disorders, highlighting the role of de novo mutations. Chromosomal microarray testing yields higher detection rates (8.3%) compared to traditional karyotyping (5.8%), enabling identification of submicroscopic deletions or duplications. These fetal-intrinsic factors underscore the value of comprehensive genetic evaluation to differentiate from other etiologies and inform recurrence risks.

Placental and Umbilical Abnormalities

Placental abnormalities, such as insufficiency, infarction, and abruption, are implicated in a substantial proportion of stillbirth cases, often through mechanisms of chronic or acute fetal hypoxia. Abnormal placental pathology demonstrates a strong association with stillbirth, with an adjusted odds ratio of 4.53 (95% CI: 1.13-18.12). Placental abruption specifically accounts for 5-10% of stillbirths, occurring in 0.6-1.2% of pregnancies overall and leading to fetal demise via hemorrhage and detachment from the uterine wall. In cases of severe abruption involving over 50% placental separation, the risk of stillbirth rises dramatically due to acute interruption of uteroplacental blood flow. Umbilical cord abnormalities, including accidents like prolapse, knots, and entanglement, contribute to 10-19% of stillbirths by compromising fetal blood flow, often via vascular occlusion or excessive traction. In a cohort of 512 rigorously evaluated stillbirths, 10.4% were attributed to cord issues, with 5.2% due to entrapment and 4.4% to knots or prolapse. True umbilical cord knots elevate stillbirth risk independently, particularly when coexisting with excessive cord length or entanglement. Nuchal cord encirclement, present in up to 30% of deliveries, shows dose-dependent association with stillbirth, with multiple loops conferring higher incidence than single loops through intermittent cord compression and reduced venous return. Single umbilical artery (SUA), occurring in approximately 1 in 200 deliveries, correlates with stillbirth via underlying vascular maldevelopment and frequent chromosomal anomalies like trisomy. These findings underscore the need for histopathological examination, as standardized criteria like the Amsterdam consensus reveal lesions in up to 89% of stillbirth placentas.

Maternal Physiological and Health Conditions

Advanced maternal age, defined as 35 years or older, is associated with an elevated risk of stillbirth, with women aged 40 years or older experiencing a 40-50% greater risk compared to those aged 20-29 years. This risk escalates further with age, as evidenced by adjusted odds ratios indicating a 1.9-fold increase for women aged 35-39 and a 2.4-fold increase for those 40 or older relative to women under 30. At term gestation (37-41 weeks), the stillbirth risk stands at approximately 1 in 382 ongoing pregnancies for ages 35-39 and 1 in 267 for ages 40 and above. Maternal obesity, characterized by a body mass index (BMI) greater than 25 kg/m², ranks as a leading modifiable risk factor for stillbirth, accounting for 8-18% of population-attributable risk across high-income countries. Meta-analyses confirm that obese women (BMI ≥30 kg/m²) face nearly twice the risk of stillbirth compared to those with normal weight (BMI 18.5-24.9 kg/m²), with the association persisting even after adjusting for confounders like diabetes and hypertension. Even modest BMI elevations, such as overweight status, correlate with incremental risks of fetal death and stillbirth, independent of gestational age. Pre-existing and gestational diabetes significantly heighten stillbirth risk, with pregestational diabetes identified as a key contributor in high-income settings. Pregnancies complicated by diabetes exhibit stillbirth rates exceeding those in uncomplicated cases, particularly when coupled with poor glycemic control or macrosomia. Similarly, hypertensive disorders, including chronic hypertension and preeclampsia, are linked to stillbirth rates of 0.3-1.9% in high-resource environments, with chronic hypertension conferring higher odds at term gestations than the corresponding infant mortality risk. Preeclampsia exacerbates placental insufficiency, a primary mechanism underlying these outcomes. Thyroid dysfunction, encompassing overt hypothyroidism, subclinical hypothyroidism, and hypothyroxinaemia, shows a modestly higher prevalence among women experiencing stillbirth compared to controls. Untreated maternal hypothyroidism is associated with adverse fetal outcomes, including increased stillbirth risk through mechanisms like impaired placental function and fetal growth restriction, though causal pathways require further elucidation. Iodine deficiency, which can precipitate thyroid issues, has been tentatively linked to stillbirth in observational data, underscoring the role of maternal endocrine homeostasis.

Modifiable Lifestyle and Environmental Factors

Maternal smoking during pregnancy is a leading modifiable risk factor for stillbirth, with meta-analyses indicating a 46% increased relative risk (summary relative risk 1.46, 95% CI 1.35-1.58) associated with any active smoking. The odds ratio rises to 1.47 (95% CI 1.37-1.57) in systematic reviews pooling data from multiple cohorts, reflecting dose-dependent effects where even low levels (1-5 cigarettes per day) elevate risk across trimesters. This association persists after adjusting for confounders like socioeconomic status and holds across high-income settings, underscoring smoking's causal role via mechanisms such as placental vasoconstriction and carbon monoxide-induced fetal hypoxia. Alcohol consumption during pregnancy also contributes, particularly at higher levels, with heavy exposure linked to elevated stillbirth rates; one cohort reported a population-attributable fraction of up to 7.9% in certain groups. Moderate intake (>5 drinks per week) carries a risk ratio of 2.96 (95% CI 1.37-6.41) compared to , primarily due to fetoplacental dysfunction, though evidence for light consumption remains inconsistent across studies. Illicit drug use, often co-occurring with and alcohol, further amplifies risks through similar vascular and toxic pathways, as noted in reviews of behavioral factors. Maternal and represent the highest-ranking modifiable factor in high-income countries, with (BMI) >25 kg/m² associated with population-attributable risks of 8-18% for stillbirth. (BMI 25-29.9) elevates risk by 20-50%, while (BMI ≥30) doubles it (60-100% increase), based on meta-analyses of cohorts exceeding 690,000 pregnancies. The association strengthens at term gestations and involves causal pathways like chronic inflammation and impaired , independent of . Supine going-to-sleep position in late pregnancy independently raises late stillbirth risk (≥28 weeks) by 2.3- to 2.63-fold (adjusted 2.63, 95% CI 1.72-4.04), as evidenced by case-control studies and meta-analyses attributing this to aortocaval compression reducing uterine blood flow. Avoidance of sleep thus offers a simple intervention, with consistent findings across populations despite limited low-resource data. Environmental exposures, including ambient fine particulate matter (PM2.5), correlate with heightened stillbirth risk, with third-trimester elevations linked to odds increases in cohort studies from regions like . Global estimates attribute a substantial burden to PM2.5, though requires further disentangling from confounders like socioeconomic factors; other pollutants (e.g., SO2, CO) show similar trimester-specific associations. Extreme heat exposure during likewise associates with adverse outcomes, potentially modifiable via behavioral adaptations like improved housing or timing of activities.

Diagnosis and Detection

Antenatal Screening Methods

Antenatal screening methods aim to identify fetal compromise, growth restriction, or that may precipitate stillbirth, particularly in high-risk pregnancies such as those involving maternal hypertension, , or prior stillbirth. These approaches include non-invasive tests like monitoring, which relies on maternal perception of reduced fetal activity as an early warning sign; observational data indicate that formalized kick counting protocols, initiated around 28 weeks, can prompt timely evaluation and potentially avert demise in up to 50% of cases with perceived alterations, though randomized trials show limited overall reduction in stillbirth rates without additional interventions. Ultrasonographic assessments form a cornerstone, with serial growth scans recommended for at-risk fetuses to detect intrauterine growth restriction (IUGR), a factor in approximately 20-30% of stillbirths; third-trimester Doppler velocimetry of umbilical and middle cerebral arteries evaluates placental blood flow resistance, with abnormal end-diastolic flow absent in the umbilical artery signaling heightened risk and warranting delivery consideration, supported by cohort studies showing 5-10 fold increased stillbirth odds in such cases. The biophysical profile (BPP) integrates a non-stress test (NST) assessing fetal heart rate reactivity to movement with ultrasound evaluation of breathing movements, body tone, gross movements, and amniotic fluid volume; a score below 6/10 correlates with a 20-30 times higher perinatal mortality risk, prompting intervention, though efficacy in averting stillbirth remains observational rather than proven in large trials. Evidence for routine screening in low-risk pregnancies is weak; for instance, early pregnancy does not demonstrably prevent stillbirth, as per systematic reviews analyzing millions of pregnancies, while in high-risk groups—starting at 32 weeks or earlier based on risk stratification—may reduce incidence by identifying actionable abnormalities like or abnormal patterns. Limitations persist, including false positives leading to unnecessary interventions and inconsistent adoption, with Cochrane analyses underscoring the need for more robust randomized data on combined protocols.

Intrapartum and Post-Delivery Confirmation

Intrapartum stillbirth, defined as fetal death after the onset of labor but prior to delivery, is typically suspected during active labor through continuous electronic fetal monitoring, which detects persistent absence of fetal heart rate (FHR) after exclusion of technical artifacts. requires real-time visualization demonstrating absent cardiac activity for at least 10 minutes, distinguishing it from transient or maternal pulse misinterpretation via Doppler . Guidelines from the American College of Obstetricians and Gynecologists (ACOG) emphasize prompt verification to guide immediate management decisions, such as proceeding to delivery without further fetal interventions. Post-delivery confirmation occurs upon expulsion of the exhibiting no signs of life, including absence of spontaneous respiration, heartbeat on , or voluntary muscle movement, as per criteria for stillbirth registration after 22 weeks gestation or 500 grams birth weight. Physical examination by the attending obstetrician assigns an of 0 at 1, 5, and 10 minutes, confirming intrauterine demise rather than neonatal , with maceration or autolysis of fetal tissues often indicating antepartum onset. In cases of intrapartum death, the appears non-macerated with potential fresh staining, prompting placental and cord inspection for acute insults like abruption. Legal reporting mandates filing a fetal within specified timelines, such as 24 hours in some jurisdictions, based on these clinical findings without requiring immediate .

Clinical Management

Labor Induction Protocols

Upon confirmation of intrauterine fetal demise, is the preferred method for delivery in most cases to minimize maternal risks such as (DIC) and , which increase with prolonged retention of the fetus. Guidelines recommend prompt induction, typically within 24-48 hours of , though women with intact membranes and no of may safely delay for up to 1-2 weeks to allow time for processing or additional testing, as the incidence of DIC remains low (under 5%) before 3-4 weeks post-demise. Expectant management beyond this period elevates DIC risk by approximately 10% due to release of from decomposing fetal-placental tissue, alongside heightened potential from retained products. Pharmacological induction with prostaglandins, particularly , is the first-line approach for gestations under 28 weeks, administered vaginally at doses of 400-800 mcg every 3-6 hours, achieving expulsion within 24 hours in over 80% of cases regardless of cervical . For later gestations or when cervical ripening is needed, a combination of (200 mg orally) followed 24-48 hours later by (400 mcg vaginally or sublingually, repeated every 3-4 hours up to 5 doses) shortens induction-to-delivery interval by 10-15 hours compared to alone, with comparable safety profiles including low rates of (under 5%) and hemorrhage. Intravenous oxytocin (starting at 1-2 mU/min, titrated up to 40 mU/min) serves as an adjunct for augmentation once active labor begins, particularly in multiparous women or after membrane rupture, yielding success rates exceeding 90% within 24-48 hours. Mechanical methods, such as transcervical , may be combined with prostaglandins for unfavorable cervices at term-equivalent gestations, reducing induction time by facilitating ripening without increasing adverse events. In women with prior cesarean sections and demise after 28 weeks, protocols mirror trial of labor after cesarean (TOLAC) criteria, favoring vaginal birth if no contraindications exist, though cesarean section rates remain higher (up to 30%) due to failed induction. Continuous fetal monitoring is unnecessary absent a live , but maternal , uterine tone, and coagulation parameters (fibrinogen, platelets) should be monitored every 4-6 hours initially, with infection prophylaxis (e.g., antibiotics) reserved for ruptured membranes or fever. Overall complication rates from induction are low (DIC <1% with timely intervention, postpartum hemorrhage 5-10%), but stillbirth delivery independently elevates severe maternal morbidity odds by 2-3 fold compared to live births, driven by factors like and hemorrhage.

Surgical Delivery Options

Cesarean delivery is generally not recommended as the primary mode for managing stillbirth due to increased maternal risks, including infection, hemorrhage, and surgical complications, without any fetal benefit. Guidelines from the American College of Obstetricians and Gynecologists (ACOG) advise reserving cesarean section for cases with specific maternal indications, such as placental abruption, severe preeclampsia, or other conditions threatening maternal health, rather than fetal demise alone. In a U.S. study analyzing 75 cases of cesarean for stillbirth before 28 weeks' gestation, prior cesarean delivery was the most frequent indication, followed by arrest of descent or other labor complications, highlighting that surgical intervention often stems from obstetric history or intrapartum issues rather than the stillbirth itself. For second-trimester stillbirths (typically 20-24 weeks' gestation), dilation and evacuation (D&E) serves as a surgical alternative to induction, involving cervical dilation followed by mechanical evacuation of the uterus under ultrasound guidance. This procedure is associated with lower maternal morbidity compared to cesarean in early gestations, with success rates exceeding 95% in experienced hands, though it requires skilled providers and may not be universally available. ACOG notes D&E as a viable option for women with prior hysterotomy, balancing efficacy against risks like uterine perforation or incomplete evacuation, which occur in less than 1% of cases per systematic reviews. In women with a previous cesarean scar, surgical delivery may involve repeat cesarean if induction risks uterine rupture, though data indicate successful vaginal delivery after prior cesarean in over 70% of intrauterine fetal demise cases with appropriate protocols, such as misoprostol or mechanical methods. Royal College of Obstetricians and Gynaecologists (RCOG) guidelines emphasize individualized assessment, favoring vaginal routes where possible but permitting cesarean for maternal stability or preference, with overall cesarean rates for stillbirth reported at 10-20% in population studies, varying by gestational age and facility resources. Post-surgical care includes monitoring for coagulopathy, as disseminated intravascular coagulation risk rises after 4 weeks of fetal demise, though prompt delivery mitigates this.

Immediate Post-Mortem Evaluation

Following confirmation of fetal demise and delivery, immediate post-mortem evaluation seeks to identify underlying causes, exclude certain etiologies, and provide information for recurrence risk counseling in subsequent pregnancies. This process, ideally initiated promptly after birth to preserve tissue viability, encompasses pathologic examination of the fetus and placenta, genetic testing, and targeted maternal investigations. Comprehensive evaluation identifies a probable cause in approximately 25-50% of cases, though a definitive explanation remains elusive in up to one-third of stillbirths despite thorough assessment. Fetal autopsy, recommended for stillbirths at or after 20 weeks gestation, involves external inspection for dysmorphic features or growth restriction, full internal dissection by a perinatal pathologist, fetal radiography to detect skeletal anomalies, photography for documentation, and selective microbiologic cultures if infection is suspected. This procedure alters or confirms the suspected cause of death in about 42% of cases and is particularly valuable for detecting congenital anomalies or unsuspected conditions like cord accidents. However, autopsy consent rates in the United States are low, at approximately 21%, often due to parental distress, cultural preferences, or logistical barriers; alternatives such as postmortem magnetic resonance imaging or minimally invasive biopsies may be offered when full autopsy is declined. Examination of the placenta, umbilical cord, and membranes—conducted immediately post-delivery with gross assessment followed by histologic analysis—represents a cornerstone of evaluation, yielding diagnostic insights in up to 65% of stillbirths. Key findings include infarction, abruption, , or cord entanglement, which may explain hypoxic or infectious etiologies; fresh placental tissue should be sampled for genetic testing if fetal blood is unavailable. Genetic testing, including chromosomal microarray analysis (CMA) on fetal tissue, cord blood, or uncultured placental villi, is advised routinely or when autopsy suggests anomalies, as it detects submicroscopic copy number variants missed by traditional karyotyping in 6-13% of cases. Whole exome sequencing may be considered in select scenarios but is not standard due to cost and interpretation challenges. Maternal blood tests, if not completed antenatally, should include screening for infections (e.g., parvovirus, syphilis serology), hemolytic disease (Kleihauer-Betke test), thrombophilias, or antiphospholipid antibodies, tailored to clinical history; these are non-invasive and support the overall diagnostic framework without delaying fetal evaluation. All procedures require informed parental consent, with multidisciplinary involvement from obstetrics, pathology, genetics, and bereavement support to facilitate decisions amid grief.

Prevention Approaches

Modifiable Risk Mitigation Strategies

Maternal smoking during pregnancy elevates stillbirth risk by approximately 47%, with cessation, particularly early in gestation, reducing this hazard through improved placental function and fetal oxygenation. Quitting before or in the first trimester can mitigate up to 20% of associated preterm-related stillbirth risks, as evidenced by cohort studies tracking smoking exposure and outcomes. Interventions including counseling and nicotine replacement therapy, when prescribed appropriately, support sustained abstinence without independently increasing stillbirth odds compared to nonsmokers. Supine sleeping position in late pregnancy doubles the odds of stillbirth, likely due to aortocaval compression reducing uterine blood flow; mitigation involves promoting left-lateral positioning, which observational data from case-control studies link to lower incidence. Positional therapy devices or behavioral education can reduce supine time by over 50% in the third trimester, offering a practical, non-invasive strategy. This risk factor accounts for a modifiable portion of late-gestation cases, independent of confounders like fetal growth restriction. Pre-pregnancy obesity (BMI >25 kg/m²) contributes 8-18% of stillbirths in high-income settings via mechanisms including and ; interpregnancy between pregnancies lowers recurrence risk by optimizing maternal metabolic health. During , gestational limits per Institute of Medicine guidelines (e.g., 5-9 kg for BMI 30-34.9) correlate with reduced adverse outcomes, though direct stillbirth causation requires vigilant monitoring rather than aggressive dieting. Comprehensive addressing comorbidities like , prevalent in obese cohorts, further attenuates elevated odds (2-5 times baseline). Periconceptional folic acid supplementation (400-800 mcg daily) reduces overall perinatal mortality by 20-30% in regions with deficiency, potentially via prevention and vascular health benefits that indirectly lower stillbirth from anomalies or growth issues. Absence of supplementation heightens risks in high-prevalence areas, with meta-analyses confirming dose-dependent protection starting pre-conception. Multiple regimens including folate show comparable efficacy to iron-folic acid alone for fetal outcomes. Avoiding illicit drugs and alcohol, which impair fetal development and placental , constitutes another modifiable domain; cohort indicate dose-response elevations in stillbirth odds, reversible through programs. Optimal interpregnancy intervals exceeding 18-24 months mitigate vascular strain from short gaps, reducing recurrence by stabilizing maternal . These strategies, when combined in targeted interventions, address up to 30% of preventable cases per population-attributable risk estimates from multinational analyses.

Healthcare System Interventions

Healthcare systems worldwide have adopted standardized care bundles as a primary intervention to reduce stillbirth rates by promoting uniform, evidence-based protocols across maternity services, targeting modifiable risks such as fetal growth restriction and reduced movements. These bundles facilitate system-wide training, auditing, and compliance monitoring to ensure high-fidelity implementation by providers.00008-0/fulltext) In the , the Saving Babies' Lives Care Bundle, mandated by in 2016 for all maternity units, incorporates five elements including support, awareness, and management of small-for-gestational-age fetuses, resulting in a reported 20% reduction in stillbirth rates among participating trusts by 2020.00008-0/fulltext) Australia's Safer Baby Bundle, implemented nationally from 2019 onward, emphasizes similar components like maternal sleep positioning and timely ultrasound screening, integrated into routine antenatal care pathways with mandatory provider education modules; evaluations indicate improved adherence to risk mitigation practices, contributing to a targeted 50% stillbirth rate reduction by 2025. System-level surveillance and confidential audits, as in the UK's model, enable ongoing refinement by analyzing causes from post-mortem data, identifying gaps in care delivery such as delayed interventions for abnormal fetal heart rates. In the United States, where stillbirth rates have stagnated around 5.7 per 1,000 births as of 2023, federal initiatives include the National Institutes of Health's September 2025 announcement of $37 million over five years for research into scalable prevention strategies, including adaptations of international bundles focused on equitable access in high-risk populations. Proposals for a national bundle advocate for rapid rollout via professional organizations like ACOG, incorporating metrics for accountability such as unit-level stillbirth audits, though implementation faces barriers in fragmented payer systems.00008-0/fulltext) Broader system interventions involve enhancing antenatal care , such as universal access to third-trimester ultrasounds for growth monitoring in low-resource settings, which meta-analyses link to 10-20% stillbirth reductions when scaled. Integrating stillbirth prevention into quality metrics for incentivizes compliance, as evidenced by declines in countries with mandatory reporting; however, disparities persist in underserved areas due to uneven resource allocation.00563-1/fulltext)

Emerging Research and Initiatives

In September 2025, the (NIH) launched the Stillbirth Prevention Consortium, allocating over $37 million across five years to identify causes of the approximately 23,600 annual U.S. stillbirths, of which 60% remain unexplained, and to develop evidence-based prevention strategies. The initiative funds four research centers focusing on placental dysfunction, patterns, maternal and stress, and for risk prediction via biomarkers, alongside a data coordinating center for analysis. Participating institutions include the , , , and Oregon Health & Science University, with goals to produce diagnostic tools and interventions targeting modifiable factors. Prevention bundles integrating multiple interventions have shown promise in reducing stillbirth rates. A proposed U.S. bundle emphasizes during , screening and management of , awareness of decreased fetal movements with prompt evaluation, avoidance of sleeping position, and counseling on third-trimester risks. In , implementation of the adapted Safer Baby Bundle—incorporating fetal growth restriction detection, fetal movement awareness, safe maternal sleep positioning, optimized birth timing for at-risk pregnancies, and intrapartum fetal monitoring—yielded a 24.8% decline in stillbirth rates from 28.6 to 21.5 per 1,000 live births across four hospitals. Similar bundles in high-income settings have correlated with reductions from 4.2 to 3.4 stillbirths per 1,000 births, underscoring the value of standardized, multifaceted protocols despite challenges in causal attribution from observational data. Emerging research on monitoring highlights its potential as an accessible prevention tool, with studies indicating that heightened maternal and can prompt timely medical intervention. Proceedings from the 2023 Stillbirth Summit emphasized uniform guidelines to foster attachment and reduce risks, supported by that over half of stillbirth cases involve prior perceived reductions in movements. Recent advancements include app-based systems and wearable devices for objective tracking, evaluated in 2024 reviews for improving detection accuracy beyond subjective maternal reports. Initiatives like Count the Kicks promote daily monitoring from 28 weeks , with 2023-2025 studies linking consistent practices to lower stillbirth incidence in monitored cohorts. Additional efforts address diagnostic gaps, such as underutilized fetal autopsies, which in 2025 analyses revealed preventable causes in cases otherwise unexplained, advocating for routine protocols to inform future pregnancies despite cultural barriers to uptake. A January 2025 consensus established a meta-core outcome set for stillbirth prevention trials, prioritizing measurable endpoints like recurrence risk and intervention efficacy to standardize research. These developments collectively aim to shift from reactive to proactive strategies, though empirical validation remains essential given persistent gaps in causal understanding.

Psychological and Long-Term Effects

Parental Grief and Mental Health Outcomes

Parents experiencing stillbirth commonly endure profound and multifaceted , characterized by intense sorrow, guilt, and emotional numbness, which can evolve into if unresolved. This bereavement process is compounded by the unique circumstances of stillbirth, including the physical trauma of labor without a live birth and frequent lack of identifiable causes, leading to heightened psychological distress. Empirical studies indicate that up to 60% of bereaved mothers exhibit symptoms consistent with complicated grief or psychiatric persisting beyond the acute phase. Bereaved mothers face substantially elevated risks of postpartum depression, with relative risks (RR) of 6.70 (95% CI 2.90–15.60) at 2 months postpartum compared to mothers of live births, declining to 2.40 (95% CI 0.83–6.90) by 8 months but remaining statistically higher in some cohorts up to 3.5 years (adjusted OR 5.34, 95% CI 2.15–13.29). Anxiety disorders are similarly prevalent, with an RR of 4.34 (95% CI 2.30–8.18) at 2 months, persisting at elevated levels (RR 2.09, 95% CI 0.92–4.74) up to 30 months. Post-traumatic stress disorder (PTSD) affects a significant proportion, with 60% of mothers meeting diagnostic criteria at 3.5 years in one longitudinal study and an overall RR of 4.36 (95% CI 2.31–8.24) within the first year; symptoms peak around 3 months and gradually decline but exceed general population rates by factors of 4–10 times. These outcomes are causally linked to the traumatic nature of unexplained fetal death, disrupted bonding expectations, and physiological hormonal shifts post-delivery, rather than mere emotional response. Fathers also experience marked mental health impairments, though prevalence may be underreported due to cultural norms discouraging in men, potentially biasing self-report data toward lower estimates. Depression risks are comparable to mothers in the acute phase (RR 5.90, 95% CI 1.20–94.00 at 2 months; RR 6.10, 95% CI 1.20–94.00 at 8 months), while anxiety shows persistent elevation (RR 4.70 at 2 months; RR 4.0 at 8 months). PTSD data for fathers is limited, but available evidence suggests 10–25% prevalence, lower than mothers' 20–40% yet still far exceeding controls (1–5%). Fathers' often manifests as instrumental —focusing on support provision or avoidance—exacerbating isolation if unaddressed, with long-term effects including strained relationships and delayed subsequent pregnancies linked to heightened anxiety. Long-term mental health trajectories show symptom attenuation over 1–3 years for most parents, yet risks remain 2–5 times higher than in non-bereaved cohorts, with subsets developing chronic conditions influenced by factors like prior history, deficits, and absence of ritual closure (e.g., seeing or holding the ). Both parents report enduring impacts on identity, trust in healthcare, and family dynamics, with mothers more prone to internalized rumination and fathers to externalized behaviors like substance use, underscoring the need for gender-differentiated assessment in empirical evaluations.

Impact on Future Reproductive Choices

Experiencing a stillbirth profoundly shapes parental decisions about future reproduction, often balancing the desire for a living against persistent fears of recurrence and emotional trauma. Approximately 60% of women who suffer a stillbirth pursue a subsequent , reflecting a common drive to rebuild family plans despite the psychological toll. Among those who conceive again, 66% do so within one year of the loss, indicating that grief does not universally deter prompt attempts, though individual timelines vary based on coping mechanisms and support. Psychological sequelae, including elevated rates of anxiety, depression, and (PTSD), frequently complicate these choices, with parents reporting intensified apprehension about fetal well-being that can delay conception or prompt early termination considerations. Studies indicate that stillbirth disrupts prior family expectations, leading some couples to forgo additional pregnancies altogether due to unresolved or perceived insurmountable risks, though quantitative data on complete cessation remains limited. Conversely, the pursuit of subsequent pregnancies is associated with heightened medical surveillance, such as increased ultrasounds and interventions, which may reassure parents and contribute to live birth rates exceeding 85% in monitored cohorts. Recurrence risks, estimated at 2.5 to nearly five times higher than baseline in subsequent gestations, inform counseling but do not universally dissuade attempts, as empirical outcomes show reduced overall stillbirth rates with proactive care. Parental decision-making is further influenced by access to multidisciplinary support, with evidence suggesting that tailored emotional and informational interventions enhance confidence in proceeding. In cases of prior congenital anomalies contributing to stillbirth, choices may lean toward or , underscoring the interplay of medical history and psychological resilience.

Societal and Policy Dimensions

Legal registration frameworks for stillbirths establish thresholds based on or fetal weight to determine mandatory reporting, enabling vital statistics compilation while generally avoiding conferral of full legal equivalent to live births. These systems vary by , with common requirements including a from attending physicians detailing the absence of at birth, such as heartbeat or respiration. The recommends treating stillbirths as distinct events, separate from live birth or registers, to accurately reflect their occurrence without implying prior legal identity. However, global adherence is incomplete, with under-registration prevalent in many countries due to resource constraints and inconsistent civil systems, affecting . In the United States, uniform federal guidelines under the Centers for Control and Prevention require all states to report fetal deaths at or after 20 weeks gestation or 350 grams via standardized fetal death certificates, which capture demographic, medical, and cause-of-death data for national aggregation without issuing birth certificates. Completion involves input from healthcare providers and, in some cases, coroners or medical examiners for cause determination, primarily serving statistical purposes rather than parental legal entitlements. A minority of states offer optional "certificates of birth resulting in stillbirth" for non-statistical, commemorative use by families. The defines a reportable stillbirth under the Births and Deaths Registration Act 1953 as delivery after 24 completed weeks gestation showing no signs of life, mandating registration within 42 days in a dedicated stillbirth register via submission of a to local authorities. Events prior to 24 weeks fall outside requirements, though hospitals provide internal documentation; this threshold aligns with viability considerations but excludes earlier losses from official counts. Registration facilitates access to bereavement services and permissions but does not generate a standard . Australia's framework, administered at the state level under births, deaths, and marriages acts, requires registration of stillbirths after 20 weeks or 400 grams , resulting in an annotated that notes the stillbirth for record-keeping and family reference. In , for instance, parents or funeral directors submit medical evidence, with no fee for the process, enabling eligibility for government benefits like . Variations persist across states—such as Queensland's emphasis on naming provisions even for stillborns—but the 20-week standard promotes comprehensive capture compared to higher thresholds elsewhere. Internationally, gestational thresholds range from 20 weeks (e.g., , ) to 24 weeks (e.g., , many nations) or 28 weeks (WHO comparability standard), often supplemented by 500-gram weight criteria in resource-limited settings to account for inaccuracies. These differences hinder rate comparisons, as lower thresholds include more antepartum events, potentially elevating reported stillbirth rates by 20-50% in adopting countries. Ongoing initiatives, such as the Global Financing Facility's roadmap, target improved protocols in 45% of nations lacking explicit stillbirth registration policies to enhance data for prevention. Registration also intersects with laws; in historical contexts like early 20th-century , unregistered stillbirths were often denied consecrated ground interment, though modern reforms in places like have expanded rights via dedicated plots upon certification.

Public Awareness and Stigma Reduction Efforts

Efforts to raise public awareness of stillbirth have proliferated through international organizations and targeted campaigns, emphasizing education on risks, prevention, and the prevalence of the issue, which affects approximately 2 million pregnancies annually worldwide. The International Stillbirth Alliance (ISA), established as a non-profit coalition, coordinates global advocacy to foster collaboration on prevention, respectful care, and awareness initiatives that challenge misconceptions and promote evidence-based interventions. Similarly, the (WHO) promotes strategies to increase societal understanding of stillbirth causes, reduce associated taboos, and integrate national targets for incidence reduction into health systems. These efforts underscore the need for empirical data dissemination, as stillbirth rates remain disproportionately high in low-resource settings, with preventable factors like fetal growth restriction contributing to over 50% of cases in some regions. National campaigns further amplify awareness by linking education to actionable behaviors. In , Red Nose's initiative, launched in coordination with health authorities, aims to cut stillbirth rates by 20% within three years through public messaging on monitoring s, , and sleep positioning, while funding research into modifiable risks. The United Kingdom's Tommy's charity hosts Baby Loss Awareness Week annually from October 9 to 15, facilitating events for remembrance, , and to normalize discussions of loss and encourage early medical consultations for reduced . In the United States, the Star Legacy Foundation advocates for recognition of the 1 in 160 stillbirth rate, pushing for policy changes and to bridge gaps in funding and risk communication. October is designated International and Loss Awareness Month, with organizations like the Stillbirth Centre of Research Excellence promoting resources for families and healthcare providers to honor losses and disseminate prevention guidelines. Stigma reduction forms a core component of these initiatives, addressing the and reported by up to 40% of bereaved parents in surveys, often exacerbated by cultural silence or attribution to maternal behavior. Peer-reviewed analyses emphasize that public campaigns targeting disadvantaged populations can mitigate this by fostering , countering myths like inevitable outcomes, and evaluating outcomes through metrics such as increased reporting and help-seeking behaviors. For instance, qualitative studies from the Parent Voices Initiative reveal that community openness about —via workplaces, families, and media—directly diminishes stigma, enabling parents to integrate their experiences without identity "spoiling." Regional examples, such as New Jersey's 2024 campaign, explicitly highlight available support services alongside risks to normalize conversations and reduce self-, drawing on data showing stigma delays subsequent care-seeking. Systematic reviews confirm that sharing personal narratives in awareness efforts repairs social identities disrupted by loss, though persistent cultural beliefs in some communities hinder progress without tailored, evidence-driven interventions.

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