Stillbirth: Causes, Risk Factors, and Prevention

Stillbirth is the death of a fetus at 28 weeks or later, occurring before or during birth. This international definition is used to compare data across countries and to plan assistance programs. Some healthcare systems use earlier thresholds for gestational age or birth weight, which complicates statistical comparisons and may underestimate the true burden of the problem. [1]

Standardizing terminology directly impacts clinical decisions and causal accounting. The World Health Organization and partners are promoting the use of the International Classification of Diseases, Eleventh Revision, and the associated ICD-PM system, which links cause of death to the mother's condition and the time of death. This allows for better identification of preventive measures, rather than simply recording the outcome. [2]

A separate distinction is made between antenatal stillbirths, when death occurs before the onset of labor, and intrapartum stillbirths, which occur during labor. The latter category is often associated with the quality of intrapartum care, timely monitoring, and access to emergency obstetric interventions. This distinction is important for the selection of preventive measures at the department level. [3]

For clinicians, the key principle is this: statistical definitions facilitate comparisons across countries, but in practice, all cases of late losses, including those between 22 and 27 weeks, should be recorded to avoid missing patterns and preventive opportunities for a specific population. This does not change international indicators, but it strengthens local quality. [4]

Finally, a common language facilitates communication with families and the interdisciplinary team, reduces discrepancies in documentation, and helps families receive accurate information about the causes and risks of future pregnancies. This increases trust and the quality of subsequent care. [5]

Table 1. Terms and why they are needed

Term	Meaning	Practical value
Stillbirth ≥28 weeks	International standard	Data comparability, global goals. [6]
Antenatal and intranatal	By time of death	Selection of preventive measures. [7]
ICD-PM	Classification of the cause taking into account the mother's condition	Targeted prevention and audit. [8]
ICD-11	Uniform accounting rules	Reducing the "gray areas" of statistics. [9]

The scale of the problem and global goals

According to estimates from a joint UN panel, approximately 1.9 million stillbirths at 28 weeks or later will occur globally in 2023. This represents approximately 5,000 losses per day, with up to 40% occurring during labor, highlighting the importance of quality intrapartum care. Despite a slow decline, progress is uneven across regions. [10]

The goal of the Global Initiative on Stillbirth Care and Prevention is to reduce national rates to 12 or fewer per 1,000 births by 2030. Interim reports show that without accelerating the implementation of evidence-based measures, many countries will not achieve the target. This makes quality programs in obstetrics and neonatology a priority. [11]

Statistics are sensitive to how gestational age and birth weight are recorded. If stillbirths are counted from 22 weeks onward, the global burden increases by approximately a third. For department-level management, it is advisable to internally record all late losses, even if the national reporting threshold is higher. [12]

Regional differences are often explained by the availability of basic services: skilled birth attendance, timely diagnosis of hypertension and diabetes, infection prevention, and transportation of pregnant women to appropriate facilities. These are manageable factors, making the problem solvable. [13]

Finally, epidemiology includes the "hidden" part—families who do not access medical care. Increasing case reporting is important not only for statistics but also for linking women to psychological and social support. [14]

Table 2. Key figures and benchmarks

Indicator	Modern assessments	Comment
Global load	About 1.9 million in 2023	Estimate for the 28-week threshold. [15]
The proportion of intrapartum	About 40%	Associated with the quality of care during childbirth. [16]
Goal by 2030	≤12 per 1000 births	Requires acceleration of the implementation of measures. [17]
Registration from 22 weeks	The load is higher by about 30%	Important for clinical audit. [18]

Causes and risk factors: what most often lies behind stillbirth

The causes are multifactorial and include fetal, placental, and maternal conditions. Common causes include placental perfusion disorders, fetal growth restriction, hypertensive disorders, diabetes mellitus, infections, and congenital anomalies. The risk increases with multiple pregnancies and unfavorable fetal presentation. The ICD-PM approach helps to structure the causes and link them to maternal conditions. [19]

Modifiable factors include smoking and exposure to tobacco smoke, obesity, undiagnosed or poorly controlled diabetes, and hypertension. Smoking cessation programs and pre-pregnancy weight control are associated with a reduced risk. Several national initiatives emphasize that early smoking cessation provides the greatest benefit. [20]

Infections remain a significant contributor in resource-limited settings. Prevention of syphilis and malaria in pregnant women, timely treatment of urinary tract infections, and appropriate management of preterm premature rupture of membranes reduce the proportion of infection-related stillbirths. This requires accessible testing, appropriate antibiotic prophylaxis, and appropriate routing. [21]

Non-modifiable factors include maternal age (under 18 or over 35 years), adverse obstetric history, congenital defects, and fetal trisomies. Timely diagnosis, counseling, and risk-based planning of the place of delivery are essential. [22]

In a significant proportion of cases, the cause remains unclear even after a full examination. This is why standardized placental pathology, genetic testing, and, with family consent, autopsy increase the rate of identified causes, which is critical for prevention in subsequent pregnancies. [23]

Table 3. Risk factors and points of application of measures

Group of factors	Examples	What can be done
Maternal	Hypertension, diabetes, obesity, smoking	Early screening, monitoring, smoking cessation. [24]
Placental	Insufficient perfusion, detachment	Early risk identification, birth planning. [25]
Fetus	Growth retardation, developmental defects	Diagnostics, monitoring, choice of place of birth. [26]
Infectious	Syphilis, malaria, urinary tract infections	Screening and treatment according to protocols. [27]

How is antenatal fetal death confirmed and what is done first?

Suspicion of antenatal death arises when there is no fetal movement and the fetal heart rate is unreassuring. The diagnosis is confirmed by ultrasound, demonstrating the absence of cardiac activity with two independent observations in an artifact-free mode. Documentation should be as clear as possible. [28]

Once confirmed, two parallel tracks are important: medical care and careful family support. The medical component includes an assessment of the mother's condition, the amount of blood loss, signs of infection, and coagulopathy. Information on delivery strategies and possible tests is also provided, without rushing the family into decisions unless there are urgent indications. [29]

Investigation into the underlying cause begins immediately: testing for infections based on the patient's medical history and indications, screening for thrombophilia in cases of recurrent losses, collecting material for genetic testing, and preparing for placental pathology. Clinical cues, rather than a desire to "do everything," guide the selection of tests. This approach saves time and resources. [30]

The team should discuss the pain management plan, induction timing, and lactation support in advance. For many families, memories and farewells are important: the opportunity to see and hold the baby, photographs, and handprints. These aren't strictly medical details, but they reduce trauma and are associated with better psychological recovery. [31]

Documentation includes consent for research and a clear plan for what will be done with the placenta and genetic material. Transparency increases trust and the family's willingness to participate in determining the cause. [32]

Table 4. First steps after confirmation of antenatal death

Direction	Actions	Target
Confirmation of diagnosis	Ultrasound with recording of absence of cardiac activity	Eliminate errors and artifacts. [33]
Mother's safety	Evaluation of infection, hemodynamics, coagulation	Timely risk correction. [34]
Examination	Infections, placenta, genetics as indicated	Determine the cause. [35]
Family support	Information, memory of the child, timing of induction	Reduce psychological trauma. [36]

Delivery in case of stillbirth

In most cases, induction of labor is indicated after confirmation of the diagnosis, taking into account the gestational age, the mother's condition, and the obstetric history. Induction methods are selected individually, taking into account the maturity of the cervix and the presence of a uterine scar. The decision is made jointly with the family unless there are immediate risks. [37]

Surgical methods are used only for strict indications. In the absence of vital indications for the mother, surgery does not improve outcomes and carries risks for future pregnancies. Exceptions include situations of severe preeclampsia, massive bleeding, severe infection, and obstetric complications, where speed is critical. [38]

Pain management, thrombosis prophylaxis, management of the third stage, and delayed cord clamping should be discussed in advance if this is consistent with the family's wishes and the clinical situation. It is important to remember the risk of coagulopathy with prolonged waiting after antenatal death, so excessive delays are undesirable. [39]

Labor management requires the same attention to gentle handling and respectful communication as for a live birth. The team prepares in advance for possible obstetric complications and supports family farewell rituals, which reduces feelings of abandonment among the parents. [40]

After delivery, the priority is to prevent bleeding, provide adequate pain relief, and gently support lactation. Options for suppressing lactation or providing symbolic support are discussed, taking into account the woman's wishes. [41]

Table 5. Delivery of stillbirth: guidelines for practice

Question	Recommendations	Justification
Timing and method	Induction in the absence of emergency indications, individual choice of methods	Safety of the mother and future pregnancies. [42]
Operation	Only for strict indications	Avoid unnecessary risks. [43]
Prevention of complications	Prevention of thrombosis, active management of the third period	Reduction of blood loss and thrombotic events. [44]
Psychological aspects	Farewell plan, lactation support	Reducing psychological trauma. [45]

Post-stillbirth screening: what to look for and how to arrange it

The minimum "gold standard" includes a thorough examination of the placenta, umbilical cord, and membranes, as well as genetic evaluation of the fetal material using methods agreed upon with the family. An autopsy is performed with parental consent, significantly increasing the detection of causes. The report is structured using the ICD-PM. [46]

Placental pathology often provides clues to diagnosis: infarctions, thromboses, villous inflammation, and problems with umbilical cord attachment. These findings help explain growth retardation, hypoxia, or acute events. It is important to properly transport and secure the specimen to avoid loss of diagnostic information. [47]

Genetic diagnostics are chosen based on clinical needs. For obvious developmental defects, targeted testing may be possible; in the absence of clues, chromosomal microarray analysis or whole-genome methods may be used, depending on local availability. Family counseling before and after testing is essential. [48]

Laboratory tests for infections are ordered on a case-by-case basis, based on epidemiology and clinical features. Routine "panels" without indications lead to high costs with low diagnostic yield. Probability-based algorithms are preferred. [49]

The final case review takes place at a multidisciplinary quality conference. The family is offered a face-to-face discussion of the results, with translation into understandable language and a written summary with recommendations for the future. This is part of respectful and high-quality care. [50]

Table 6. Required components of examination after stillbirth

Component	For what	Comment
Placental and umbilical cord pathology	Common root cause	Requires proper transportation. [51]
Genetics	Identification of chromosomal and genomic causes	Selection of method based on clinical situation and agreement. [52]
Infections	Targeted diagnostics	Algorithm by probability. [53]
ICD-PM	A common language of reasons	Improving comparability and prevention. [54]

Prevention: from the clinic to the system

At the clinical level, the set of measures includes the identification of high-risk pregnant women and the initiation of outpatient fetal monitoring if the risk indicator is above the threshold level, which is generally considered to be 0.8 cases per thousand births or more. Non-stress testing, a biophysical profile, and daily fetal movement testing are used when appropriate. [55]

Preventive interventions include smoking cessation, weight management, screening and management of hypertension and diabetes, timely diagnosis and management of fetal growth restriction, information about decreased fetal movements, and improved intrapartum care and referral to appropriate facilities. This is supported by reviews and clinical programs. [56]

Systematic measures in institutions—standards for monitoring during labor, staff training in recognizing distress and rapid team action, and auditing intrapartum stillbirths to identify organizational bottlenecks—provide quick wins without complex technologies. [57]

In resource-limited countries, the most effective interventions are basic packages: skilled birth attendance, infection prevention and treatment during pregnancy, timely induction in post-term pregnancies, and access to emergency cesarean sections when indicated. Quality programs in obstetrics and neonatology have demonstrated a significant reduction in intrapartum losses. [58]

Finally, fetal movement awareness programs and fast-track routes when fetal movements are reduced reduce delays in seeking care. This is especially effective when combined with an accessible midwife line and the availability of rapid fetal assessment visits. [59]

Table 7. Preventive measures

Level	Measures	Expected effect
Individual	Smoking cessation, weight control, blood pressure and glycemia control	Reducing antenatal risk. [60]
Outpatient observation	Non-stress test, biophysical profile according to indications	Early detection of fetal distress. [61]
Intranatal care	High-quality monitoring, fast decisions	Fewer intrapartum losses. [62]
Community	Awareness of movements, quick access to help	Reducing processing delays. [63]

Family support, risk of relapse and planning for the next pregnancy

The loss of a child is a difficult event that requires careful communication and wording. Acknowledging the child's identity, offering memorial rituals, and respectfully discussing autopsy and other tests without pressure or the option to refuse are recommended. Support for the partner and family is included from the outset. [64]

The risk of recurrence depends on the cause. If factors such as smoking are eliminated and conditions are controlled, the risk in subsequent pregnancies decreases. In cases of placental insufficiency or fetal growth restriction, more frequent visits and Doppler ultrasound are scheduled, and the timing of delivery is discussed. The family is provided with a written care plan. [65]

Not everyone needs psychological support, but it should be accessible to everyone. It is important to offer group and individual formats, support addresses, and a plan for a follow-up meeting in a few weeks to discuss assessment results. This reduces the risk of long-term post-traumatic stress. [66]

Before planning a subsequent pregnancy, it is recommended to control chronic conditions, normalize body weight, quit smoking, and take folate supplements. For rare causes, such as thrombophilia, the plan should be coordinated with specialized specialists. This increases the likelihood of a successful outcome. [67]

It's important for families to know that most subsequent pregnancies end successfully with proper planning and care. Assertive and respectful communication from the medical team helps families cope with the loss and return to plans for their child. [68]

Table 8. After stillbirth: what to offer the family

Direction	What to include	For what
Communication and memory	Rituals, photographs, prints, personalized certificates	Psychological support. [69]
Medical resume	Reason based on examination results, observation plan	Reducing the risk of recurrence. [70]
Psychological help	Individual and group formats	Reducing post-traumatic stress. [71]
Plan for the next pregnancy	Risk factor control, observation schedule	Increasing the likelihood of a successful outcome. [72]

A short conclusion for practice

Stillbirth is often preventable. The most effective methods are standardized definitions and assessment of causes according to the ICD-PM, high-quality intrapartum care, targeted outpatient monitoring for those at high risk, smoking cessation, and management of chronic conditions. Equally important are respectful communication and comprehensive evaluation after loss, as they pave the way for prevention in subsequent pregnancies. [73]