From invisibility to visibility: Global initiatives make progress in incorporating stillbirths into their publications

In 2016, The Lancet’s Ending preventable stillbirth series presented a call to action to end preventable stillbirths by 2030. One simple action was for global partners to appropriately integrate stillbirths in women’s and children’s health initiatives, action plans, programs, publications and monitoring. A mapping of women’s and children’s health initiatives and related publications between 2011-2015, conducted for the series, demonstrated the failure to consistently and meaningfully include stillbirths in the post-2015 health agenda.

In an effort to track progress, members of the Stillbirth Advocacy Working Group conducted a similar analysis looking at the year 2018 to see if key maternal and newborn health (MNH) resources contained references to stillbirths. The resources include strategic plans, progress reports, guidelines and several special commissions. Criteria considered and resources included are listed below.

Overall, we are pleased to note that attention to stillbirths seem to be gradually increasing since last measured in 2016. Out of 22 resources examined, 16 made reference to stillbirths, and some extensively so. We believe this indicates good progress in acknowledging the burden of stillbirths and in tackling the silence so often associated with these largely preventable deaths.

We are encouraged by the leadership shown by UNICEF and WHO in taking steps to address this important issue in 2018. The UNICEF/WHO’s ‘Every Newborn Progress Report’, the WHO guidelines on ‘Intrapartum care for a positive childbirth experience’, UNICEF guidelines on conducting perinatal death reviews and the joint statement on ‘Defining competent maternal and newborn health professionals’ are all examples of this. These resources integrate references to stillbirths throughout and provide good examples of how countries can improve the recording of stillbirths and put in place measures to enhance the quality of care during pregnancy and childbirth to help prevent these deaths. The UNICEF ‘Every Child Alive’ report features a section on stillbirths and the WHO ‘Guidelines on health policy and system support to optimize community-based health worker programmes’ references the value of community health workers in helping to reduce stillbirths.

2018 also saw important opportunities for the demonstration of global commitment to maternal and newborn health, including improving the coverage and quality of MNH services. The Countdown 2030 progress report, the Partnership for Maternal, Newborn and Child Health (PMNCH) 2018 report on Commitments to the Every Woman Every Child (EWEC) Strategy, the 2018 Independent Accountability Panel report, the Guttmacher-Lancet Commission on ‘Accelerating progress – sexual and reproductive health and rights for all’ and the joint WHO-UNICEF Survive and Thrive report all include reference to stillbirths, and the WHO network on quality of care ‘Quality, Equity, Dignity’ (QED) includes the reduction of stillbirths in its strategic goals.

It is encouraging to note that two out of three major global publications in 2018 on quality of health care make specific reference to stillbirths in relation to improving antenatal care quality (the Lancet Commission on High Quality Health Systems) and to enhancing community level demand for quality health care (the National Academy of Sciences – Crossing the Global Quality Chasm: Improving Healthcare Worldwide). The third publication, from WHO, Organisation for Economic Co-operation and Development (OECD) and the World Bank on Delivering Quality Health Services, does not specifically reference stillbirths, but does make multiple references to improving the quality of maternal and newborn care.

Despite this progress, there is still much work to do. The lack of inclusion of any reference to stillbirths in some of these resources is a serious gap. For example, neither of the new UNICEF or UNFPA Strategic Plans 2018-2021 mention stillbirths, although both agencies are very actively working to improve the quality of maternal health care and, therefore, reduce stillbirths. The UN Inter-Agency Group for Child Mortality Estimation (UN-IGME) report for 2018 also failed to make any reference to stillbirths despite ongoing efforts to include these data in mortality estimates.

Furthermore, the UNICEF report on ‘Progress for Every Child in the SDG Era’ does not mention stillbirths; neither does the Joint UN Global Action Plan for Healthy Lives and Wellbeing for all, although it has many references to MNH. While the inclusion of reduction of stillbirths in the WHO QED network is commendable, there is no further detail mentioned in the elaboration of strategic objectives or the logical framework model. In WHO’s ‘Recommendations on home-based records for maternal, newborn and child health’, there is also limited reference to stillbirths. Finally, the PMNCH report on commitments to EWEC notes that only 5% of commitments include a reference to reducing stillbirths and that progress in reducing stillbirths is slower than progress in reducing maternal or under-five mortality. These gaps belie the strong efforts being made in countries by the UN agencies and others to address the root causes of stillbirths and highlight the ongoing need for greater consistency across the wide range of resources published.

Family planning is a widely acknowledged contributor to improved maternal health and the consequent reduction of maternal and newborn mortality and stillbirths. Yet, none of these (mostly preventable) deaths receive a mention in the FP2020 progress report for 2018. Again, this fails to use all opportunities to emphasize the important links between good maternal health and potential reductions in stillbirth rates.

As we move further into 2019, it is clear that, while we are making good progress, we still need to continue advocating for greater attention to stillbirths and systematic inclusion of stillbirths in all aspects of MNH and related resources.

Criteria and resources considered in analysis

Criteria for appropriate inclusion of stillbirth outlined in The Lancet’s Ending preventable stillbirth series:

  • acknowledge the burden of stillbirths
  • address actions needed to prevent stillbirths with high quality antenatal and intrapartum care
  • monitor stillbirths with a target or outcome indicator, or both.

List of resources review:

 


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