TY - JOUR
T1 - Global, regional, and national stillbirths at 20 weeks' gestation or longer in 204 countries and territories, 1990–2021
T2 - findings from the Global Burden of Disease Study 2021
AU - GBD 2021 Global Stillbirths Collaborators
AU - Comfort, Haley
AU - McHugh, Theresa A.
AU - Schumacher, Austin E.
AU - Harris, Ashley
AU - May, Erin A.
AU - Paulson, Katherine R.
AU - Gardner, William M.
AU - Fuller, John E.
AU - Frisch, Meghan E.
AU - Taylor, Heather Jean
AU - Leever, Andrew T.
AU - Teply, Corey
AU - Verghese, Nicholas Alexander
AU - Alam, Tahiya
AU - Abate, Yohannes Habtegiorgis
AU - Abbastabar, Hedayat
AU - Abd-Elsalam, Sherief
AU - Abdelmasseh, Michael
AU - Abd-Elsalam, Sherief
AU - Abdissa, Daba
AU - Abdoun, Meriem
AU - Abdulkader, Rizwan Suliankatchi
AU - Abebe, Mesfin
AU - Abedi, Aidin
AU - Abidi, Hassan
AU - Abiodun, Olumide
AU - Aboagye, Richard Gyan
AU - Abolhassani, Hassan
AU - Abrigo, Michael R.M.
AU - Abu-Gharbieh, Eman
AU - Abu-Rmeileh, Niveen ME
AU - Adane, Mesafint Molla
AU - Addo, Isaac Yeboah
AU - Adema, Bulcha Guye
AU - Adesina, Miracle Ayomikun
AU - Adetunji, Charles Oluwaseun Oluwaseun
AU - Adeyinka, Daniel Adedayo
AU - Adnani, Qorinah Estiningtyas Sakilah
AU - Afzal, Saira
AU - Agampodi, Suneth Buddhika
AU - Agodi, Antonella
AU - Agyemang-Duah, Williams
AU - Ahinkorah, Bright Opoku
AU - Ahmad, Aqeel
AU - Ahmadi, Ali
AU - Ahmed, Luai A.
AU - Ahmed, Haroon
AU - Ahmed, Luai A.
AU - Ajami, Marjan
AU - Akinosoglou, Karolina
AU - Al Hasan, Syed Mahfuz
AU - Al-Aly, Ziyad
AU - Alam, Khurshid
AU - Alanezi, Fahad Mashhour
AU - Alanzi, Turki M.
AU - Albashtawy, Mohammed
AU - Alemi, Sharifullah
AU - Algammal, Abdelazeem M.
AU - Al-Gheethi, Adel Ali Saeed
AU - Ali, Abid
AU - Ali, Liaqat
AU - Alif, Sheikh Mohammad
AU - Aljunid, Syed Mohamed
AU - Almazan, Joseph Uy
AU - Al-Mekhlafi, Hesham M.
AU - Almidani, Louay
AU - Almustanyir, Sami
AU - Altirkawi, Khalid A.
AU - Aly, Hany
AU - Aly, Safwat
AU - Amani, Reza
AU - Ameyaw, Edward Kwabena
AU - Amhare, Abebe Feyissa
AU - Amin, Tarek Tawfik
AU - Amiri, Sohrab
AU - Andrei, Catalina Liliana
AU - Andrei, Tudorel
AU - Anoushiravani, Amir
AU - Ansar, Adnan
AU - Anvari, Davood
AU - Anwer, Razique
AU - Appiah, Francis
AU - Arab-Zozani, Morteza
AU - Aravkin, Aleksandr Y.
AU - Areda, Demelash
AU - Aregawi, Brhane Berhe
AU - Artamonov, Anton A.
AU - Aryal, Umesh Raj
AU - Asemi, Zatollah
AU - Asemu, Mulu Tiruneh
AU - Asgedom, Akeza Awealom
AU - Ashraf, Tahira
AU - Asresie, Melash Belachew
AU - Atlaw, Daniel
AU - Atout, Maha Moh d.Wahbi
AU - Atreya, Alok
AU - Atteraya, Madhu Sudhan
AU - Aujayeb, Avinash
AU - Ayala Quintanilla, Beatriz Paulina
AU - Ayatollahi, Haleh
AU - Ayyoubzadeh, Seyed Mohammad
AU - Azadnajafabad, Sina
AU - Azevedo, Rui M.S.
AU - Azzam, Ahmed Y.
AU - B, Darshan B.
AU - Babaei, Mahsa
AU - Badar, Muhammad
AU - Badiye, Ashish D.
AU - Baghcheghi, Nayereh
AU - Baghdadi, Soroush
AU - Bagheri, Nasser
AU - Bagherieh, Sara
AU - Bahrami Asl, Farshad
AU - Bai, Ruhai
AU - Bakshi, Ravleen Kaur
AU - Bam, Kiran
AU - Banach, Maciej
AU - Banke-Thomas, Aduragbemi
AU - Bansal, Hansi
AU - Bantie, Berihun Bantie
AU - Barchitta, Martina
AU - Bardhan, Mainak
AU - Bashiri, Azadeh
AU - Basiru, Afisu
AU - Baskaran, Pritish
AU - Batra, Kavita
AU - Bayani, Mojtaba
AU - Bayleyegn, Nebiyou Simegnew
AU - Bedi, Neeraj
AU - Begum, Tahmina
AU - Behnoush, Amir Hossein
AU - Belgaumi, Uzma Iqbal
AU - Bermudez, Amiel Nazer C.
AU - Beyene, Kebede A.
AU - Bhandari, Bharti Bhandari
AU - Bhandari, Dinesh
AU - Bhardwaj, Nikha
AU - Bhardwaj, Pankaj
AU - Bhaskar, Sonu
AU - Bhattarai, Suraj
AU - Bodolica, Virginia
AU - Braithwaite, Dejana
AU - Brenner, Hermann
AU - Bustanji, Yasser
AU - Butt, Nadeem Shafique
AU - Butt, Zahid A.
AU - Cadri, Abdul
AU - Campos-Nonato, Ismael
AU - Cattaruzza, Maria Sofia
AU - Cembranel, Francieli
AU - Cerin, Ester
AU - Chacón-Uscamaita, Pamela Roxana
AU - Charan, Jaykaran
AU - Chattu, Vijay Kumar
AU - Chauhan, Dhun
AU - Chavula, Malizgani Paul
AU - Chen, Simiao
AU - Chi, Gerald
AU - Chitheer, Abdulaal
AU - Cho, William C.S.
AU - Choudhari, Sonali Gajanan
AU - Chu, Dinh Toi
AU - Cruz-Martins, Natalia
AU - Dadras, Omid
AU - Dagnew, Gizachew Worku
AU - Dalaba, Maxwell Ayindenaba
AU - Dandona, Lalit
AU - Darwesh, Aso Mohammad
AU - Das, Jai K.
AU - Das, Saswati
AU - Dash, Nihar Ranjan
AU - Dávila-Cervantes, Claudio Alberto
AU - Davletov, Kairat
AU - Debela, Berhanu Gidisa
AU - Debele, Aklilu Tamire
AU - Derese, Msganaw
AU - Deribe, Kebede
AU - Dervišević, Emina
AU - Dessie, Anteneh Mengist
AU - Dhali, Arkadeep
AU - Dhulipala, Vishal R.
AU - Dirac, M. Ashworth
AU - Dong, Wanyue
AU - Dora, Bezabih Terefe
AU - Dsouza, Haneil Larson
AU - Duraes, Andre Rodrigues
AU - Dutta, Sulagna
AU - Dziedzic, Arkadiusz Marian
AU - Ed-Dra, Abdelaziz
AU - Edvardsson, Kristina
AU - Eini, Ebrahim
AU - Ekholuenetale, Michael
AU - El Sayed Zaki, Maysaa
AU - Elgendy, Islam Y.
AU - Elhadi, Muhammed
AU - Elshaer, Mohammed
AU - Elsohaby, Ibrahim
AU - Emeto, Theophilus I.
AU - Engelbert Bain, Luchuo
AU - Esayas, Hawi Leul
AU - Eshrati, Babak
AU - Esposito, Francesco
AU - Fagbamigbe, Adeniyi Francis
AU - Fakhradiyev, Ildar Ravisovich
AU - Faramarzi, Ali
AU - Faro, Andre
AU - Fatehizadeh, Ali
AU - Fekadu, Ginenus
AU - Fischer, Florian
AU - Fomenkov, Artem Alekseevich
AU - Fukumoto, Takeshi
AU - Gaal, Peter Andras
AU - Gaidhane, Abhay Motiramji
AU - Gajdács, Márió
AU - Galali, Yaseen
AU - Gallus, Silvano
AU - Ganesan, Balasankar
AU - Gazzelloni, Federica
AU - Gebrehiwot, Mesfin
AU - Gebremedhin, Amanuel Tesfay
AU - Gebremeskel, Teferi Gebru
AU - Geda, Yohannes Fikadu
AU - Gezae, Kebede Embaye
AU - Ghazy, Ramy Mohamed
AU - Gheno, Gloria
AU - Gialluisi, Alessandro
AU - Gissler, Mika
AU - Glasbey, James C.
AU - Glasstetter, Logan M.
AU - Golechha, Mahaveer
AU - Goleij, Pouya
AU - Golinelli, Davide
AU - Grivna, Michal
AU - Guha, Avirup
AU - Guicciardi, Stefano
AU - Guo, Hanbing
AU - Gupta, Sapna
AU - Gupta, Veer Bala
AU - Gupta, Vivek Kumar
AU - Haller, Sebastian
AU - Halwani, Rabih
AU - Hamidi, Samer
AU - Handal, Alexis J.
AU - Haro, Josep Maria
AU - Hartman, Nicholas Nathaniel
AU - Hasan, Taufiq
AU - Hasanpour- Dehkordi, Ali
AU - Hasnain, Md Saquib
AU - Hassanipour, Soheil
AU - He, Wen Qiang
N1 - Funding Information:
This project was supported by the Bill & Melinda Gates Foundation. Editorial note: The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.
Publisher Copyright:
© 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license
PY - 2024/11/16
Y1 - 2024/11/16
N2 - Background: Stillbirth is a devastating and often avoidable adverse pregnancy outcome. Monitoring stillbirth levels and trends—in a comprehensive manner that leaves no one uncounted—is imperative for continuing progress in pregnancy loss reduction. This analysis, completed as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, methodically accounted for different stillbirth definitions with the aim of comprehensively estimating all stillbirths at 20 weeks or longer for 204 countries and territories from 1990 to 2021. Methods: We extracted data on stillbirths from 11 412 sources across 185 of 204 countries and territories, including 234 surveys, 231 published studies, 1633 vital statistics reports, and 10 585 unique location-year combinations from vital registration systems. Our final dataset comprised 11 different definitions, which were adjusted to match two gestational age thresholds: 20 weeks or longer (reference) and 28 weeks or longer (for comparisons). We modelled the ratio of stillbirth rate to neonatal mortality rate with spatiotemporal Gaussian process regression for each location and year, and then used final GBD 2021 assessments of fertility and all-cause neonatal mortality to calculate total stillbirths. Secondary analyses evaluated the number of stillbirths missed with the more restrictive gestational age definition, trends in stillbirths as a function of Socio-demographic Index, and progress in reducing stillbirths relative to neonatal deaths. Findings: In 2021, the global stillbirth rate was 23·0 (95% uncertainty interval [UI] 19·7–27·2) per 1000 births (stillbirths plus livebirths) at 20 weeks' gestation or longer, compared to 16·1 (13·9–19·0) per 1000 births at 28 weeks' gestation or longer. The global neonatal mortality rate in 2021 was 17·1 (14·8–19·9) per 1000 livebirths, corresponding to 2·19 million (1·90–2·55) neonatal deaths. The estimated number of stillbirths occurring at 20 weeks' gestation or longer decreased from 5·08 million (95% UI 4·07–6·35) in 1990 to 3·04 million (2·61–3·62) in 2021, corresponding to a 39·8% (31·8–48·0) reduction, which lagged behind a global improvement in neonatal deaths of 45·6% (36·3–53·1) for the same period (down from 4·03 million [3·86–4·22] neonatal deaths in 1990). Stillbirths in south Asia and sub-Saharan Africa comprised 77·4% (2·35 million of 3·04 million) of the global total, an increase from 60·3% (3·07 million of 5·08 million) in 1990. In 2021, 0·926 million (0·792–1·10) stillbirths, corresponding to 30·5% of the global total (3·04 million), occurred between 20 weeks' gestation and 28 weeks' gestation, with substantial variation at the country level. Interpretation: Despite the gradual global decline in stillbirths between 1990 and 2021, the overall number of stillbirths remains substantially high. Counting all stillbirths is paramount to progress, as nearly a third—close to 1 million in total—are left uncounted at the 28 weeks or longer threshold. Our findings draw attention to the differential progress in reducing stillbirths, with a high burden concentrated in countries with low development status. Scarce data availability and poor data quality constrain our capacity to precisely account for stillbirths in many locations. Addressing inequities in universal maternal health coverage, strengthening the quality of maternal health care, and improving the robustness of data systems are urgently needed to reduce the global burden of stillbirths. Funding: Bill & Melinda Gates Foundation.
AB - Background: Stillbirth is a devastating and often avoidable adverse pregnancy outcome. Monitoring stillbirth levels and trends—in a comprehensive manner that leaves no one uncounted—is imperative for continuing progress in pregnancy loss reduction. This analysis, completed as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, methodically accounted for different stillbirth definitions with the aim of comprehensively estimating all stillbirths at 20 weeks or longer for 204 countries and territories from 1990 to 2021. Methods: We extracted data on stillbirths from 11 412 sources across 185 of 204 countries and territories, including 234 surveys, 231 published studies, 1633 vital statistics reports, and 10 585 unique location-year combinations from vital registration systems. Our final dataset comprised 11 different definitions, which were adjusted to match two gestational age thresholds: 20 weeks or longer (reference) and 28 weeks or longer (for comparisons). We modelled the ratio of stillbirth rate to neonatal mortality rate with spatiotemporal Gaussian process regression for each location and year, and then used final GBD 2021 assessments of fertility and all-cause neonatal mortality to calculate total stillbirths. Secondary analyses evaluated the number of stillbirths missed with the more restrictive gestational age definition, trends in stillbirths as a function of Socio-demographic Index, and progress in reducing stillbirths relative to neonatal deaths. Findings: In 2021, the global stillbirth rate was 23·0 (95% uncertainty interval [UI] 19·7–27·2) per 1000 births (stillbirths plus livebirths) at 20 weeks' gestation or longer, compared to 16·1 (13·9–19·0) per 1000 births at 28 weeks' gestation or longer. The global neonatal mortality rate in 2021 was 17·1 (14·8–19·9) per 1000 livebirths, corresponding to 2·19 million (1·90–2·55) neonatal deaths. The estimated number of stillbirths occurring at 20 weeks' gestation or longer decreased from 5·08 million (95% UI 4·07–6·35) in 1990 to 3·04 million (2·61–3·62) in 2021, corresponding to a 39·8% (31·8–48·0) reduction, which lagged behind a global improvement in neonatal deaths of 45·6% (36·3–53·1) for the same period (down from 4·03 million [3·86–4·22] neonatal deaths in 1990). Stillbirths in south Asia and sub-Saharan Africa comprised 77·4% (2·35 million of 3·04 million) of the global total, an increase from 60·3% (3·07 million of 5·08 million) in 1990. In 2021, 0·926 million (0·792–1·10) stillbirths, corresponding to 30·5% of the global total (3·04 million), occurred between 20 weeks' gestation and 28 weeks' gestation, with substantial variation at the country level. Interpretation: Despite the gradual global decline in stillbirths between 1990 and 2021, the overall number of stillbirths remains substantially high. Counting all stillbirths is paramount to progress, as nearly a third—close to 1 million in total—are left uncounted at the 28 weeks or longer threshold. Our findings draw attention to the differential progress in reducing stillbirths, with a high burden concentrated in countries with low development status. Scarce data availability and poor data quality constrain our capacity to precisely account for stillbirths in many locations. Addressing inequities in universal maternal health coverage, strengthening the quality of maternal health care, and improving the robustness of data systems are urgently needed to reduce the global burden of stillbirths. Funding: Bill & Melinda Gates Foundation.
UR - http://www.scopus.com/inward/record.url?scp=85208667403&partnerID=8YFLogxK
U2 - 10.1016/S0140-6736(24)01925-1
DO - 10.1016/S0140-6736(24)01925-1
M3 - Article
C2 - 39510107
AN - SCOPUS:85208667403
SN - 0140-6736
VL - 404
SP - 1955
EP - 1988
JO - The Lancet
JF - The Lancet
IS - 10466
ER -