The Global Burden of Stillbirths

Global Health & Gender Policy Brief No.
5 l June 2023
Photo courtesy of: Jlhinton / flickr (CC BY-ND 2.0)
The Global Burden of Stillbirths

OVERVIEW
Every 17 seconds, one stillbirth occurs. A baby who dies at or after 28 weeks of pregnancy,* and is
born with no sign of life is classified as a stillbirth.1 In 2021, 1.9 million stillbirths occurred globally.2
Stillbirths can be caused by pregnancy and childbirth-related complications, like hemorrhage, placental
abruption, and pre-eclampsia; maternal infections during pregnancy, including malaria and sexually
transmitted infections; prolonged pregnancy to 42 weeks or more; and pre-existing health conditions.3
Other risk factors include maternal age and smoking during pregnancy.4
Since 2000, stillbirth rates have declined by 35%–but this reduction pales in comparison to other
significant strides made in preventing newborn and child death.5 For example, under five mortality rates
declined by 50% in the same period.6 Global momentum to address stillbirths hasn’t generated the same
progress and results, in part due to limited national policies and gaps in data collection and analysis. Many
governments do not have explicit stillbirth reduction targets or collect data on stillbirths.7
Without intervention, 15.9 million babies will be stillborn between now and 2030.8 Increased research
and political attention to stillbirths offers an opportunity to accelerate progress and reduce this number.
This policy brief will lay out the multi-faceted impacts of stillbirth on community, individuals, and
society, and offer recommendations for increasing attention and action in preventing stillbirth and to
creating healthy and supportive environments for families who have experienced stillbirth.
This brief was prepared by Sarah B. Barnes, Sophia DeLuca, Maanasa Chitti and Deekshita Ramanarayanan through the generous support of EMD
Serono, the healthcare business of Merck KGaA, Darmstadt, Germany.
*Definitions of stillbirth vary globally. The definition from the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) is a baby born with no sign of life at
28 weeks of pregnancy or later. Other definitions include a baby born with no sign of life as early as 20- or 24-weeks’ gestation.
Maternal Health
Initiative
THE INEQUALITY OF STILLBIRTH create feelings of isolation.16 In 2016, 4.2 million
women were reportedly living with depression
Stillbirth is a global health issue that affects
related to a stillbirth.17 Studies also noted potential
millions of families each year–but the impacts
stigmatization, rejection, or abuse of mothers
aren’t equally distributed. The country with the
of a stillborn in certain situations, predominantly
highest stillbirth rate has a rate 20 times higher
in low-and-middle- income countries (LMIC).18
than the country with the lowest rate.9 Data
Grief, anxiety, and post-traumatic stress have
from 2021 shows stillbirths concentrated in Sub-
been shown to affect the entire family following
Saharan Africa (45%) and Central and Southern
a stillbirth.19 The loss of a child can have long-
Asia (33%).10 The stillbirth rate in Sub-Saharan
lasting effects, including decreased self-esteem
Africa was 21 per 1000 total births, compared to
and loss of identity, particularly for women.20
just 2.9 in Europe, Northern America, Australia,
The suddenness of stillbirth, the unknown cause
and New Zealand.11 The current global target is 12
of a stillbirth, the need to place blame, and the
or fewer stillbirths per 1,000 total births in every
emotional and financial stress on families add
country by 2030.12
additional psychological consequences.21
These regional inequities are also mirrored in
number of preventable stillbirths. In 2021, two ECONOMIC IMPACT
in every five global stillbirths occurred during For the individual family, the cost of a stillbirth
labor (intrapartum). Most intrapartum stillbirths can be substantial. A study quantifying the cost
are preventable with monitoring and timely of stillbirth in Australia from time of birth to two
intervention.13 There are disproportionately high years postpartum found that out of pocket fees
rates of intrapartum stillbirth in some regions– for parents were 52% higher for those who had
close to 50% of stillbirths in Sub-Saharan a stillbirth as compared to those who had a live
Africa, Central and Southern Asia, and Oceania birth.22 A study conducted in England and Wales
were intrapartum, in stark contrast with just found that expenditure on health services during
13% intrapartum stillbirths in Europe, Northern a subsequent pregnancy was much higher for
America, Australia, and New Zealand.14 pregnant people who had experienced a stillbirth
without a known cause.23 Costs for national
PSYCHOLOGICAL IMPACT governments are also significant. The same study
To better address stillbirth in policy and practice, conducted in Australia found that the overall cost
its psychological impact must be understood. The to the government was 42% higher for a stillbirth
2022 United Nations Children’s Fund (UNICEF) than a live birth.24
stillbirth estimates report, “Never Forgotten,”
A systematic review of the economic burden of
spotlighted the stories of grieving families and
stillbirth in high-income countries found high costs
healthcare providers and demonstrated the
associated with stillbirth beyond direct hospital
immense loss, depression, anxiety, confusion,
bills or future medical expenses.25 One study
and love experienced after a stillbirth.15 Stillbirth,
in the United Kingdom found that 97% of total
and subsequent care, can impact intimate
cost from a stillbirth comes from indirect costs
relationships, lead to increased pressure to either
including grieving parents’ reduced work hours,
quickly conceive again or delay conception, and
extended time off work, and decreased overall
GLOBAL HEALTH & GENDER POLICY BRIEF

No. 5 l June 2023
Photo courtesy of: Black Brush / Shutterstock.com
productivity. Additionally, funeral costs, like burial occurring in the 29 countries with 2023 UN
plots and services, and lawsuits led by parents Humanitarian Appeals.29 This is an increase
over issues like hospital negligence add to a from 2022, when 38% of stillbirths occurred in
family’s financial burden.26 However, the research humanitarian settings.30
supporting these findings was conducted in high
Disruptions to supply chains, caused by
income countries, presenting a limited view of
COVID-19, conflict, and the climate crisis,
the indirect costs of stillbirth in low- and middle-
have dramatically pushed up the cost of living
income countries, where the prevalence and for millions of people.31 A healthy economy
burden of stillbirth are often higher. is associated with low and declining levels of
stillbirth, while economic recession and increased
STILLBIRTHS IN EMERGENCIES & cost of living is associated with an increase in the
HUMANITARIAN SETTINGS prevalence of stillbirths.32, 33
“The ‘four C’s’ – conflict, climate change, Research on climate and environmental impacts
COVID-19, and the cost-of-living crisis heighten shows direct and indirect effects of climate
threats for the most vulnerable women and change on stillbirths.34 As climate change
babies in all countries,” states the newly continues to progress and intensify without
launched Born Too Soon report, which details unified global action, rising temperatures and
the global state of preterm birth, including natural disasters will continue to be risk factors for
stillbirths.27 The highest risk of stillbirth occurs stillbirth. A 2021 study of weather data from 14
in humanitarian settings28 with 51% of stillbirths LMIC countries was the first to establish a “strong

No. 5 l June 2023
correlation” between extreme heat and stillbirth.35 public transportation may have impacted patients
Extreme heat events have since become more in rural areas.43
frequent and more severe, often occurring in
differential seasonal patterns—making them less EXISTING GLOBAL INITIATIVES
predictable.36 Air pollution has also been linked ADDRESSING STILLBIRTH
to increased risk of stillbirth. One study found
Every Newborn Action Plan (ENAP): ENAP
that approximately 40% of stillbirths across 137
was initially launched in 2014 by the World Health
countries in Asia, Africa, and Latin America were
Organization (WHO) and UNICEF, among other
attributed to ambient fine particles, which are
partners, and endorsed by 194 member states.
primarily produced through the burning of fossil
ENAP acts as a “road map” to end newborn
fuels.37 Toxic pollutant particles have been found
mortality, maternal mortality, and stillbirths. ENAP
in the lungs, livers, and brains of fetuses and black
initially set goals and targets for 2020, addressing
carbon particles have been found in cord blood,
a gap in the United Nations Millennium
proving the ability of these particles to enter the
Development Goals: stillbirths and newborn
fetal circulation system via the placenta.38
deaths were not originally mentioned.
Research is varied and ongoing on the effects of
In 2014, ENAP set a goal for all countries to
COVID-19 on stillbirths. One US study found that
achieve fewer than 14 stillbirths per 1000 total
women with COVID-19 at the time of delivery
births by 2020, less than 12 by 2030, and less
were at increased risk for stillbirth compared to
than 10 by 2035.44 In 2020, the ENAP progress
women without COVID-19.39 A systematic review
report tracked success and stagnation of ENAP
and meta-analysis including 40 studies found a
goals. While 87% of countries defined a newborn
significant increase in stillbirth during the pandemic
mortality reduction target, only 32% had a
as compared to data prior to the pandemic.40 This
stillbirth reduction target. Approximately 60%
rise in stillbirths may be attributed to changes in
of countries were not on track to meet the 2020
obstetric services, potentially resulting from staff
stillbirth reduction goal of 14 or fewer stillbirths
shortages or reduced antenatal visits, ultrasound
per 1000 total births. Of all high burden countries,
scans, and screening during the first few months of
just 44% had a research agenda that included
lockdown.41 Additionally, the pandemic may have led
stillbirth research and social, behavioral and
to the underdiagnosis of pregnancy complications,
community engagement research.
such as gestational hypertension, as women had
fewer face-to-face antenatal visits, limiting the At the recent International Maternal and Newborn
opportunity for proper assessment and monitoring.42 Health Conference (IMNHC), ENAP and the
Ending Preventable Maternal Mortality (EPMM)
One analysis of the association between
initiative launched a joint 2023 progress report
COVID-19 and stillbirth found that indirect causes
detailing the ENAP-EPMM shared global targets
of increased stillbirth could include resistance to
of 90% coverage of four or more antenatal care
seeking care at the hospital due to fear of infection
contacts and 90% of births attended by skilled
or stress of overburdening health services. Public
birth attendants to reduce maternal and newborn
campaigns to reduce unnecessary hospitalization
morbidity, mortality, and stillbirths.45
may have discouraged some pregnant people
from seeking care when needed and disruptions in

No. 5 l June 2023
Photo courtesy of: MMPhoto21 / Shutterstock.com
United Nations Inter-Agency Group for Child International Stillbirth Alliance (ISA): ISA was
Mortality Estimation (UN IGME): UN IGME is led founded in 2003 by three American mothers
by UNICEF and was formed in 2004 with the central who experienced stillbirth and is focused on
goals of sharing child mortality data and improving global stillbirth prevention and bereavement
individual country capacities to collect data and care. ISA works to raise awareness; connect
create data estimations. 2018 was the first year UN parents, researchers, and doctors; and increase
IGME developed specific indicators for stillbirth, stillbirth-related research. At IMNHC, ISA
which were published in 2020.46 The process for launched the “Global Guide for Stillbirth Advocacy
including stillbirth indicators in UN IGME estimates and Implementation,” which brings together
include compiling data, processing it, creating existing resources and practical guidance for
a statistical model for each country, creating governments, ministries of health, professional
estimates for stillbirth rates, and disseminating organizations, as well as parents, community
information. Country consultation was conducted leaders, parent organizations, health workers, and
throughout.47 UN IGME global and country data others to prevent stillbirth and improve care for
and indicators help fill a long-standing gap in women and families who experience stillbirth.48
standardized stillbirth data and estimates, increasing
awareness of the state of stillbirth globally.

No. 5 l June 2023
POLICY RECOMMENDATIONS
1. Increase data on stillbirths to decrease prevalence. The significance of stillbirths needs to be measured
globally and each stillbirth must be counted. Currently, stillbirths are not counted in preterm burden
estimates, which reflect live births only. Countries must also include surveillance and data collection
for stillbirths and cause of death in national maternal and newborn health plans to supplement
stillbirth estimates from UN IGME. Both Bangladesh and Algeria, countries highlighted by UNICEF’s
“Never Forgotten” stillbirth estimates report saw significant reductions in stillbirth rates after they made
improvements in data collection and stillbirth surveillance.49 In addition to strong surveillance systems,
additional training for healthcare workers is essential to avoid the misclassification of stillbirths
as neonatal deaths or miscarriages. These misclassifications may be due to confusion around stillbirth
definitions, or intentional to avoid blame or additional burden on healthcare workers.50 While WHO and
UNICEF define stillbirths as a baby that dies at or after 28 weeks of gestation,51 other definitions of stillbirth
in research include deaths as early as 20 or 24 weeks, making data across studies non-comparable.
2. Reduce the stigma, taboo, and misconception of stillbirth. When women are blamed for stillbirth, there
is a higher risk of negative mental health conditions, isolation, and abuse or rejection from spouses or
families.52 Studies show that many women who experience stillbirth need positive support from networks,
including family and friends after a stillbirth, to reduce negative outcomes.53 Respectful healthcare is also
essential for women, during and after a stillbirth. Policy makers should support programs that include
training for healthcare providers on how to implement respectful maternity care guidelines, including
mental health support for parents following a stillbirth.54
3. Set national and local stillbirth reduction targets. Setting national targets and priorities for stillbirth
reduction encourages investment and commitment from government and health experts. In 2020, the
ENAP progress report found that just 32% of countries had a stillbirth reduction target. Sub-national targets
are essential alongside national targets to evaluate equity and distribute resources well.55
4. Invest in strengthening health systems to provide high-quality care, particularly in humanitarian

settings and regions with the highest prevalence of stillbirths. Intrapartum stillbirths account for 40%
of all stillbirths, almost all of which are preventable with access to timely and high-quality care.56 In order
to reduce preventable stillbirths, increased investment in high-quality care, including training more skilled
birth workers, like midwives, is needed. Increased coverage of international-standard midwives can
lead to stillbirth reduction.57 A Lancet study using the “Lives Saved Tool” modeled the potential impact of
increasing access to quality midwifery care in LMICs. The model estimates that even a modest increase of
midwifery coverage of 10% every 5 years would avert 14% of all stillbirths each year.58 Access to antenatal
care is another essential first step in reducing stillbirths.59 Bangladesh and Rwanda, two high burden
countries, were spotlighted by the “Never Forgotten” stillbirth estimates report for significant reductions
after they improved antenatal care quality and access.60
5. Enact supportive policies for working parents who experience loss. Bereavement or parental leave
policies must be implemented to account for the emotional and economic impacts for parents who
experience stillbirth. In some countries, there are existing policies to address paid bereavement or
parental leave after a stillbirth or child death. For example, in the United Kingdom, workers are eligible
for two weeks of paid bereavement leave after a stillbirth or child death.61 In New Zealand, this paid leave
is just three days long62 and in the United States, there is no guaranteed paid leave in the case of stillbirth.
The US Family Medical Leave Act (FMLA) allows certain eligible workers to take 12 weeks of unpaid leave
for serious health conditions, including miscarriage and stillbirth,63 and some cities or municipalities have
implemented bereavement leave policies that include stillbirth in accordance with FMLA,64 but these
policies are in no way inclusive of all workers.

No. 5 l June 2023
ENDNOTES
1 “Stillbirth.” (2023, January). UNICEF Data. UNICEF, https://data.unicef.org/topic/child-survival/stillbirths/.
2 “Stillbirth.” (2023, January). UNICEF Data. UNICEF, https://data.unicef.org/topic/child-survival/stillbirths/.
3 “Stillbirth.” World Health Organization Health Topics. World Health Organization, https://www.who.int/health-topics/still-
birth#tab=tab_1.
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5 “Never Forgotten: The Situation of Stillbirth around the Globe.” UNICEF Data. UNICEF, January 16, 2023. https://data.unicef.org/
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16 Burden, C, Bradley, S., Storey, C., Ellis, A., Heazell, A., Downe, S., Cacciatore, J., and Siassakos, D. “From Grief, Guilt Pain and
Stigma to Hope and Pride – A Systematic Review and Meta-Analysis of Mixed-Method Research of the Psychosocial Impact of
Stillbirth.” BMC Pregnancy and Childbirth 16, no. 1 (2016). https://doi.org/10.1186/s12884-016-0800-8.
17 Leisher, S H., Lawn, J., Kinney, M., Kuo, N., and De Bernis, Luc. “Brief for GSDR–2016 Update: Stillbirths: Investment in
Ending Preventable Stillbirths by 2030 Will Yield Multiple Returns and Help Achieve Multiple Sustainable Development Goals.”
The Lancet Ending Preventable Stillbirths Series Advisory and Study Group, https://sustainabledevelopment.un.org/content/
documents/975137_Leisher%20et%20al._Stillbirths-Investment%20in%20ending%20preventable%20stillbirths%20by%20
2030%20will%20yield%20multiple%20returns%20and%20help%20achieve%20multiple%20Sustainable%20Develop-
ment%20Goals.pdf.
20 “What You Need to Know about Stillbirths: Answers to Common Questions about This Tragic Loss of Life.” UNICEF, January 10,
2023. https://www.unicef.org/stories/what-you-need-to-know-about-stillbirths.
21 Gopichandran, V., Subramaniam, S. & Kalsingh, M.J. “Psycho-social impact of stillbirths on women and their families in Tamil
Nadu, India – a qualitative study.” BMC Pregnancy Childbirth 18, 109 (2018). https://doi.org/10.1186/s12884-018-1742-0
22 Callander, E. J., Thomas, J., Fox, H., Ellwood, D., & Flenady, V. (2020). “What are the costs of stillbirth? Capturing the direct
health care and macroeconomic costs in Australia.” Birth (Berkeley, Calif.), 47(2), 183–190. https://doi.org/10.1111/birt.12469

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23 Mistry, H., Heazell, A.E.P., Vincent, O. et al. “A structured review and exploration of the healthcare costs associated
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28 “Surviving Day One: Caring for Mothers and Newborns in Humanitarian Emergencies on the Day of Childbirth.” Child Rights
Resource Center. Inter-Agency Working Group on Reproductive Health in Crises, Save the Children US, https://resourcecentre.
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29 “Preventing Maternal and Newborn Mortality with Quality, Respectful, and Dignified Care from Pregnancy through the Post-
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30 Tappis, H., Bryce, E., and Boerma, T. “Tracking Progress in Mortality Reduction in Humanitarian Settings.” AlignMNH: Collective
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34 McElroy, S., Ilango, S., Dimitrova, A., Gershunov, A., and Benmarhnia, A. “Extreme Heat, Preterm Birth, and Stillbirth: A Global
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No. 5 l June 2023
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Maternal Health Initiative

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Deekshita Ramanarayanan | Program Associate
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[email protected]
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Global Health & Gender Policy Brief No.

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The Global Burden of Stillbirths

GLOBAL HEALTH & GENDER POLICY BRIEF

GLOBAL HEALTH & GENDER POLICY BRIEF

GLOBAL HEALTH & GENDER POLICY BRIEF

GLOBAL HEALTH & GENDER POLICY BRIEF

4. Invest in strengthening health systems to provide high-quality care, particularly in humanitarian

GLOBAL HEALTH & GENDER POLICY BRIEF

GLOBAL HEALTH & GENDER POLICY BRIEF

GLOBAL HEALTH & GENDER POLICY BRIEF

GLOBAL HEALTH & GENDER POLICY BRIEF

Woodrow Wilson International Center for Scholars

The Wilson Center

Maternal Health Initiative

GLOBAL HEALTH & GENDER POLICY BRIEF

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