[Cause Exploration Prizes] Preventing stillbirths

This essay was submitted to Open Philanthropy’s Cause Exploration Prizes contest.

If you’re seeing this in summer 2022, we’ll be posting many submissions in a short period. If you want to stop seeing them so often, apply a filter for the appropriate tag!

Author’s note: This cause area exploration is far from the depth and clear conclusions I would want and is in parts clearly in draft mode. Open Phil encouraged me to submit regardless and publish properly later. I will do this to encourage myself to actually finish it at a later date and not forget the post in the drawer.

This submission might change focus later: I could imagine improved antenatal and labour care to have wider benefits on child health than reducing stillbirths.

Summary

Two million babies are stillborn every year. A baby is called stillborn if they die after 28 weeks of pregnancy. Most charitable interventions focus on children already born despite babies being much more vulnerable in the last trimester. Almost half of all stillborn babies were still alive until labour started, passing away hours or mere minutes before they were born. Stillbirths are usually not given a DALY weighting so are ignored in cost-effectiveness analysis. Interventions reducing maternal and child deaths often reduce stillbirths as well, so they are more cost-effective than they first appear.

Intragovernmental bodies as well as philanthropists have shown much less interest in reducing stillbirths compared to maternal and child deaths. This gives philanthropists the opportunity to save more lives by focusing on stillbirths.

To a first approximation, children become less vulnerable as they get older. Adjusting for the length of the time period, the stillbirth rate is much higher than the infant mortality rate which in turn is much higher than the under 5’s mortality rate. Although birth is the riskiest period.

As philanthropists we have already noticed that focusing on young children is often most cost-effective. All recommended GiveWell charities above the GiveDirectly bar are focusing on the lives of young children. Trying to reduce stillbirths by improving care of pregnant women would just be going one step further in this direction.

Uncertainties

Major

This submission primarily discusses stillbirths. But the potential interventions to reduce stillbirths have wider benefits. I do not know what fraction of the benefits of the interventions actually accrue as stillbirth prevention. Therefore it is possible a later publication will pivot into antenatal interventions and/or labour care more widely.
As of now, his post is missing plenty of potential interventions, instead just giving a cursory overview, as well as lacking cost-effectiveness estimates. Therefore it is hard to say whether it is a plausible competitive cause area candidate.

Minor

Some data is a bit outdated. This seems particularly risky due to geographic shift in stillbirths.
I have not paid enough attention to different risk factors by geography.

Importance

Two million babies are stillborn every year. A baby is called stillborn if they die after the 28th week of pregnancy but before they are born.^[1] If born in a rich country, most of these babies would live. In the UK, a baby born at 28 weeks is around 90% likely to survive up to virtually a hundred percent if full-term.

This is especially true for the almost half of all stillbirths in which the baby only dies after labour has already started.

A sharp discontinuity in health cost-effectiveness analysis such that a baby passing away minutes after birth should be given the full QALY weighting while a baby passing away minutes before should be ignored seems hard to defend.

Babies passing away before birth has the same set of harms as children dying: not only do they lose their life, their families are bereaved.

Neglectedness

While child deaths and maternal deaths have received a lot of attention from intragovernmental bodies and philanthropists, this is less true for stillbirths.

The Global Burden of Disease Study ignores stillbirths completely.

While stillbirths feature in the Sustainable Development Goals, no goal is defined for them, unlike for child and maternal mortality. Stillbirths were not mentioned at all in the Millenium Development Goals.

At least the WHO introduced the Every Newborn Action Plan which tries to reduce neonatal deaths (which constitute 45% of child deaths before age 5) as well as stillbirths.

The fight for babies to be born alive has unfortunately made less progress than saving children already born, suggesting relative neglectedness. Child mortality has declined by about half since 2000, while stillbirths have only declined by a third during that time. The same pattern holds for neonatal deaths, which have also only declined by a third.

In annual terms, progress in reducing stillbirths between 2000 and 2015 has been less fast than progress in reducing maternal, neonatal and postneonatal deaths. Stillbirths are estimated to have reduced by 2% yearly, while maternal and neonatal deaths have declined by around 3% and postneonatal deaths by 4.5% yearly.^[2]

While there are foundations working on stillbirths, they are usually focused on stillbirths in rich countries (like in the UK, Australia or the US).

Given the relative lack of interest by intragovernmental bodies and philanthropists as well as slow progress compared to child mortality, I expect a funder putting stillbirths in focus to be able to have a larger impact.

Tractability

Most stillbirths, as most child deaths, are highly preventable. High-income countries in Europe or North America have a stillbirth rate of only 3 per 1,000 births while ~14 babies are stillborn for every 1,000 births worldwide. [source] Almost half of stillbirths happen in Sub-Saharan Africa and a third in Central and South Asia [source].

Stillbirths occurring late in pregnancy and during labour require different responses. To prevent babies dying during birth, most needed is high-quality labour care. I will not investigate this.

For saving babies during the last trimester, stillbirths have a variety of risk factors and different promising interventions. As with reducing child mortality, my best guess is that the most cost-effective interventions will be found in pure health interventions.

To take malaria as an example:

Not only do 400,000 children under 5 die of malaria each year, another 200,000 are stillborn. To a first approximation this implies that for every two children saved from malaria due to a community-wide distribution of malaria nets, one baby will be born alive who would have been stillborn.

Babies in the last trimester of pregnancy are much more vulnerable to malaria than children already born.

Yet stillbirths due to malaria are ignored in GiveWell’s cost-effectiveness estimates for a life saved by AMF. They are only mentioned as “supplemental intervention-level adjustment”, assuming to make AMF 9% better than it appears from cost per life saved.

Risk factors for stillbirth are (non-exhaustive) infections, maternal disorders like hypertension and diabetes, late maternal age and pregnancy lasting longer than 42 weeks. Fetal growth restriction is also a risk factor. Women who did not have any antenatal care have a much higher risk of their babies being stillborn. [source]

The UN report on stillbirths states [source]:

“Within low- and middle-income settings, infection (e.g. malaria, syphilis, HIV) is one of the top five causes of stillbirths, with the percentage of stillbirths attributed to maternal infection ranging from 8 to 50 per cent. In sub-Saharan Africa, malaria is estimated to contribute to 20 per cent of stillbirths and syphilis is attributed to more than an estimated 11 per cent of stillbirths. “

The Lancet series on preventable stillbirths states: “Many disorders associated with stillbirths are potentially modifiable and often coexist, such as maternal infections (population attributable fraction: malaria 8·0% and syphilis 7·7%), non-communicable diseases, nutrition and lifestyle factors (each about 10%), and maternal age older than 35 years (6·7%). Prolonged pregnancies contribute to 14·0% of stillbirths. Causal pathways for stillbirth frequently involve impaired placental function, either with fetal growth restriction or preterm labour, or both.”

Malaria nets could also be handed out during antenatal visits. If overhead could be kept small this could be highly cost-effective as about 5% (approximate from this study) of pregnant women have malaria in late pregnancy.

Syphilis intervention seems particularly promising.

“In sub-Saharan Africa, where the prevalence of syphilis is highest, WHO estimated that only 51% of women attending antenatal clinics were screened for syphilis in 2012. [...] Point-of-care tests are available for syphilis that need only one drop of blood, cost less than US$1, require no laboratory equipment, and provide a result in 15 min.[...] The problem is that most policy makers and health professionals seem unaware of the number of babies who die needlessly of syphilis.” [source]

40% of babies born to women with untreated syphilis can be stillborn or die from infection as a newborn. [CDC source] 2.9% of pregnant women in Subsaharan Africa have syphilis. [source]

Syphilis treatment is best done as early as possible in pregnancy. Unfortunately while a lot of women in Subsaharan Africa do have at least one antenatal visit it is rarely in the first trimester. [More info here.]

Improving the number of antenatal visits or having one at all could be promising. Having no antenatal visits seems to be particularly dangerous. Cash incentives or similar could be used to encourage antenatal visits. A Cochrane review thinks this likely increases the frequency of antenatal visits, but does not encourage initiation of antenatal care, but the evidence is poor.

Encouraging the first antenatal visit might be particularly valuable compared to encouraging more, but they might be in a harder to reach population, so it is not immediately obvious which number of visits might be the most cost-effective to encourage.

The UN report on stillbirths lists the following priorities for prevention:

Monitor and manage fetal growth restriction
Prevent and manage infectious diseases, obesity, diabetes and hypertension
Provide intrapartum monitoring for every woman and baby
Ensure referral pathways and remove barriers to specialized care
Invest in implementable clinical pathways to manage intrapartum complications
Provide assisted vaginal or C-section deliveries if needed
Provide post-term labour induction if appropriate

What should funders do

In addition to the potential interventions mentioned in the tractability section, the following are possibilities:

GiveWell might consider including stillbirths in their cost per life saved calculations, or at least add more accessible information on them, as it shifts the number substantially. Community-wide malaria net distributions also save babies during pregnancy, early childhood vaccinations do not. If there is room for more funding in a multitude of charities with similar cost per life saved, this implies that charities which also save babies during pregnancy should be prioritised.

Improved labour care is more cost-effective than it looks, because plenty of stillborn babies will be saved too. Someone else has submitted an entry for the contest on improving labour care to reduce neonatal deaths.

Data on stillbirths, especially in low-income countries, is often very weak. This makes it hard to target interventions well. While this is more meta and speculative than funding targeted interventions, funding for improving data could be promising. This could involve lobbying and financial help for stillbirth certificates or community surveys on stillbirth.

“Among the 195 countries for which the UN IGME generates stillbirth estimates, 62 countries – nearly a third – have either no stillbirth data (24 countries) or no quality data (38 countries).” [source]

^
Definitions for stillbirths differ in some places, sometimes paying attention to birth weight or defining stillbirths after week 20 or 24.
^
These numbers look slightly inconsistent.