Long-Term Trends in Fetal Mortality: Implications for Developing Countries /Tendances a Long Terme De la Mortalite Foetale: Implications Pour le Pays En developpement/Mortalidad Fetal: Tendencias a Largo Plazo E Implicaciones Para Los Paises En Desarrollo

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Historical trends in late-fetal mortality in developed countries may have important implications for both the current level and future trends in developing countries. In developing countries, the reduction of child mortality remains one of the chief objectives for public health programmes, but little attention is given to fetal mortality. (1,2) In many developed countries, while absolute rates have never been lower, late-fetal mortality is now higher than infant mortality. Perinatal deaths are the principal subject of concern among obstetricians and paediatricians. The causes of antepartum stillbirths and the survival of preterm live births represent two important areas for research and policy initiatives. The reduction of intrapartum stillbirths to 10% or less of all late-fetal deaths is credited to the availability of effective birth attendants supported by skilled obstetricians, advanced medical technology and specialized institutional facilities. How did the developed countries reach this fortunate, although still challenging, position and what are the implications for developing countries where early-age mortality remains high and fetal health is not yet a priority?

This question has several complicated aspects. The definitions of miscarriage, abortion (induced, unsafe and natural), stillbirth or late-fetal death, viability and live birth are particularly complicated, socially as well as biologically constructed, and subject to variation. (3) This variability will affect the prospects for accurate recording in registration systems, community and hospital surveys, together with those for measurement and comparison. Since the immediate causes of fetal deaths may be difficult to identify, even with the aid of postmortem examinations, the ultimate causes (e.g. maternal physique, infection, poor midwifery) are also likely to be difficult to identify.

Data problems: developed countries

European countries have adopted a variety of different practices for stillbirth and live birth registration, and this limits the comparative value of perinatal mortality as an index of healthcare. (4) Also, in countries where legal abortion is used as a form of birth control, the registration of stillbirths, live births and neonatal deaths has a different meaning from those countries where abortion is uncommon or illegal. (5) h has also been common practice in several countries (e.g. Belgium, France, Spain) to register as live births only those infants who survived for a specified period beyond birth. Those who did not survive were placed in a category often known as "false stillbirths" or they were completely ignored for registration purposes. Despite these problems, and there are others, there is a long and remarkably rich history of attempts to register late-fetal deaths in many developed countries. Indeed, the very commitment to registration signifies an appreciation of the importance of perinatal health and the need to monitor progress. (6)

Fig. 1 draws on registration data from 11 countries to illustrate the course of late-fetal mortality over the longest period of time possible. It shows time-series for the stillbirth rate (SBR), i.e. registered stillbirths per 1000 total births (stillbirths plus live births). Usually, the terms stillbirth, late-fetal death and dead born can be regarded as synonymous since they relate to the birth of a fetus of more than 28 weeks gestation showing no vital signs, but this is not always the case. The 11 countries can be divided into three groups determined by the length of the registration period and the sorts of problems to which the resulting data are exposed. In the first group we have Denmark, Iceland, Norway and Sweden with registration dating from at least the early years of the 19th century (1750s in Sweden shown in Fig. 1 as a solid line for decades), a reputation for high quality (especially from the 1870s) and a commitment to state support for midwifery services. …