Making stillbirths visible: A systematic review of globally reported causes of stillbirth

Background: Stillbirth is a global health problem. The World Health Organization (WHO) application of the International Classification of Diseases for perinatal mortality (ICD-PM) aims to improve data on stillbirth to enable prevention. Objectives: To identify globally reported causes of stillbirth, classification systems, and alignment with the ICD-PM. Search strategy: We searched CINAHL, EMBASE, Medline, Global Health, and Pubmed from 2009 to 2016. Selection criteria: Reports of stillbirth causes in unselective cohorts. Data collection and analysis: Pooled estimates of causes were derived for country representative reports. Systems and causes were assessed for alignment with the ICD-PM. Data are presented by income setting (low, middle, and high income countries; LIC, MIC, HIC). Main results: Eighty-five reports from 50 countries (489089 stillbirths) were included. The most frequent categories were Unexplained, Antepartum haemorrhage, and Other (all settings); Infection and Hypoxic peripartum (LIC), and Placental (MIC, HIC). Overall report quality was low. Only one classification system fully aligned with ICD-PM. All stillbirth causes mapped to ICD-PM. In a subset from HIC, mapping obscured major causes. Conclusions: There is a paucity of quality information on causesof stillbirth globally. Improving investigation of stillbirthsand standardisation of audit and classification is urgently needed and should be achievable in all well-resourced settings. Implementation of the WHO Perinatal Mortality Audit and Review guide is needed, particularly across high burden settings