Ending preventable stillbirths and improving bereavement care: a scorecard for high- and upper-middle income countries

Key messages1. Wide disparities in stillbirth rates exist between and within high- and upper-middle income countries, indicating that further reduction in stillbirth rates is possible.The existence of disparities in stillbirth rates across high- and upper-middle income countries shows that further improvements in stillbirth prevention are possible and makes the continued reduction of stillbirth rates a public health imperative. This includes balanced measures to ensure that stillbirth prevention strategies do not result in an increase in related perinatal outcomes, such as preterm birth and neonatal death.2. Numerous disparate national stillbirth definitions are used in high- and upper-middle income countries, limiting comparisons necessary to drive change.The use of multiple definitions for stillbirth and related perinatal outcomes makes it difficult to assess and compare individual countries' performance, and to use data for advocacy and accountability for stillbirth prevention and support. Universal definitions specific to high- and upper-middle income countries should be developed and used.3. Data on key risk factors and equity in stillbirth rates are limited, however, underline the need for increased focus on the most affected communities.Tracking stillbirth rates associated with risk factors such as socio-economic deprivation and adolescent, or unplanned pregnancies can help in the development, adaptation and implementation of stillbirth prevention strategies. Yet these data are often lacking. Similarly, data on equity in stillbirth and related birth outcomes can help to inform stillbirth prevention strategies; however, such data are frequently unavailable, contributing to insufficient targeting of at-risk populations. National equity targets for birth outcome are required.4. Most high- and upper-middle income countries lack guidelines and targets on key areas critical for stillbirth prevention and care after stillbirth, including national stillbirth rate targets.The absence of guidelines and targets on key areas critical for stillbirth prevention and care after stillbirth means healthcare providers, civil society and other stakeholders have no benchmarks or criteria to hold the healthcare system accountable or to measure quality of care. We identified several targets that could be incorporated into guidance for improved quality of care, including setting of national stillbirth rate targets.5. Most high- and upper-middle income countries do not have guidelines around bereavement care, or mechanisms in place for reduction of stigma.Stigma enables the perpetuation of common myths around stillbirth, such as the belief that stillbirth is inevitable. Putting mechanisms in place to reduce stigma and developing guidelines for appropriate bereavement care should be a priority. BackgroundDespite progress, stillbirth rates in many high- and upper-middle income countries remain high, and the majority of these deaths are preventable. We introduce the Ending Preventable Stillbirths (EPS) Scorecard for High- and Upper Middle-Income Countries, a tool to track progress against the Lancet's 2016 EPS Series Call to Action, fostering transparency, consistency and accountability.MethodsThe Scorecard for EPS in High- and Upper-Middle Income Countries was adapted from the Scorecard for EPS in Low-Income Countries, which includes 20 indicators to track progress against the eight Call to Action targets. The Scorecard for High- and Upper-Middle Income Countries includes 23 indicators tracking progress against these same Call to Action targets. For this inaugural version of the Scorecard, 13 high- and upper-middle income countries supplied data. Data were collated and compared between and within countries.ResultsData were complete for 15 of 23 indicators (65%). Five key issues were identified: (1) there is wide variation in stillbirth rates and related perinatal outcomes, (2) definitions of stillbirth and related perinatal outcomes vary widely across countries, (3) data on key risk factors for stillbirth are often missing and equity is not consistently tracked, (4) most countries lack guidelines and targets for critical areas for stillbirth prevention and care after stillbirth and have not set a national stillbirth rate target, and (5) most countries do not have mechanisms in place for reduction of stigma or guidelines around bereavement care.ConclusionsThis inaugural version of the Scorecard for High- and Upper-Middle Income Countries highlights important gaps in performance indicators for stillbirth both between and within countries. The Scorecard provides a basis for future assessment of progress and can be used to help hold individual countries accountable, especially for reducing stillbirth inequities in disadvantaged groups.

Automated summary

Wide disparities in stillbirth rates exist between and within high- and upper-middle income countries, indicating that further reduction in stillbirth rates is possible. Numerous disparate national stillbirth definitions are used in these countries, limiting comparisons necessary to drive change. Data on key risk factors and equity in stillbirth rates are limited, however, underline the need for increased focus on the most affected communities.