GFF Roadmap for improved stillbirth reporting and response Teuk Thla Health Center in The Global Financing Facility (GFF) has been partnering with countries Phnom Penh, Cambodia. Photo: © Dominic Chavez since 2015 to accelerate progress in the health outcomes for women The Global Financing Facility children, and adolescents. Central to the GFF’s country-led approach is the development of a costed prioritized investment case to provide a roadmap for achieving universal coverage of a package of reproductive, maternal, child, adolescent health, and nutrition (RMNCAH-N) services. The 2021-2025 GFF Strategy affirms this approach with a renewed focus on country leadership, equity, high-quality health services, sustainable health financing, and improved use of data for decision-making. Improved monitoring of stillbirth is an important part of this Strategy, as it is both a sensitive indicator of poor quality care during pregnancy and childbirth and a critical component of data for decision making. The following report addresses what has until now been a gap in GFF’s 2 RMNCAH-N agenda. Why is counting stillbirths important for Global Financing Facility (GFF)- supported countries? Each year, globally, nearly 2 million pregnancies result in stillbirths. The COVID-19 pandemic has led to a significant increase in stillbirths (1). The Every Newborn Action Plan (ENAP), antenatal and intrapartum care has been led by the World Health Organization underestimated, with missed opportunities (WHO) and UNICEF and endorsed by 194 for scaling up more specific interventions WHO member states, calls for each country to end preventable stillbirths. to achieve a rate of 12 stillbirths or fewer per 1,000 total births by 203 (2). Almost all The first step for countries to prevent 37 GFF-supported countries 1 are off track to stillbirths is to accurately identify and report reach their stillbirth targets of 12 stillbirths them. Although the availability of stillbirth or fewer per 1,000 total births, translating data is improving, it is still very limited in into about half a million lives lost (Table 1). low and middle-income countries (LMIC), where 84% of stillbirths occur. Nearly Most stillbirths are preventable, and high one-third of the 195 countries studied by stillbirth rates are a marker of low access the United Nations Inter-agency Group for and coverage of quality antenatal and Child Mortality Estimation (UN IGME) had intrapartum care. Notably, 42% of stillbirths no stillbirth data (24 countries) or lacked occur between the onset of labor and birth (1). high-quality data (38 countries). Currently, This percentage is even higher in sub- these national data systems do not record Saharan Africa and Central and Southern stillbirths, or the stillbirth data is unusable Asia, where about half of all stillbirths due to non-standard definitions, inaccurate occur during the intrapartum period (1). classification, or underreporting (1). Intrapartum stillbirth is a tragedy since timely interventions could have prevented Not counting the stillbirths occurring a majority of these deaths. For too long, annually in the GFF-supported countries is stillbirths have not been included when a missed opportunity for measuring impact assessing the impact of poor quality and return on investments. The UN IGME antenatal and intrapartum care. Stillbirths estimated that 22.1 million pregnancies will have received less attention as a public result in a stillbirth between now and 2030 health issue than neonatal, under-five if the stillbirth rate for each country stays mortality, and maternal mortality: During at the 2019 level (1). Across the 37 GFF- the past two decades, the annual rates supported countries, if the ENAP stillbirth of reduction of stillbirths have been much target of 12/1000 total births was reached, smaller than reductions in neonatal deaths, over 500,000 stillbirths would be averted deaths among children ages 1-59 months, each year based on 2019 estimates (Table 1). and maternal deaths (1). Consequently, the benefit of investing in improved 1 This includes 36 GFF partner countries + Honduras (a GFF eligible country that received emergency COVID-19 EHS grant co-financing on an exceptional basis). GFF ROADMAP FOR IMPROVING MONITORING AND DATA SYSTEMS TO COUNT AND ACCOUNT FOR STILLBIRTHS 3 Table 1. GFF-supported countries: Stillbirth rates, numbers of stillbirths, and stillbirths that could be averted if ENAP target were met IGME stillbirth Estimated Stillbirths averted rate estimates number of if ENAP target (stillbirths per 1000 stillbirths in 2019 of 12 stillbirths/ total births)(1)2,3 (IGME) 1000 total births were met 4 COUNTRY 2010 2019 Afghanistan 32.6 28.4 35,384 20,433 Bangladesh 29.7 24.3 72,508 36,702 Burkina Faso 23.7 19.5 15,141 5,823 Cambodia 16.5 12.5 4,573 183 Cameroon 21.7 19.4 17,872 6,817 Central African 32.5 29.8 5,147 3,074 Republic Chad 30.1 27.5 18,802 10,597 Cote d'Ivoire 26.8 23.2 21,735 10,493 DRC 30.1 27.2 98,871 55,251 Ethiopia 31.1 24.6 90,323 46,263 Ghana 25.1 21.7 19,529 8,730 Guatemala 15.9 12.7 5,498 303 Guinea 26.8 25.2 11,895 6,231 Haiti 22.6 19.9 5,470 2,172 Honduras 10.1 8.5 1,787 - Indonesia 11.9 9.5 45,857 - Kenya 20.6 19.7 30,030 11,738 Liberia 25.4 24.2 4,008 2,021 Madagascar 17.5 16.5 14,671 4,001 Malawi 20.0 16.3 10,440 2,754 4 IGME stillbirth Estimated Stillbirths averted rate estimates number of if ENAP target (stillbirths per 1000 stillbirths in 2019 of 12 stillbirths/ total births)(1)2,3 (IGME) 1000 total births were met 4 COUNTRY 2010 2019 Mali 23.0 19.7 16,251 6,352 Mauritania 25.4 22.0 3,385 1,539 Mozambique 25.5 21.7 25,096 11,218 Myanmar 16.3 14.1 13,493 2,010 Niger 21.9 19.6 21,283 8,253 Nigeria 23.7 22.2 171,428 78,764 Pakistan 36.5 30.6 190,483 115,784 Rwanda 18.9 16.9 6,798 1,971 Senegal 22.6 19.7 11,157 4,361 Sierra Leone 27.7 23.7 6,249 3,085 Somalia 29.1 26.8 17,738 9,796 Tajikistan 10.9 9.0 2,542 - Tanzania 21.8 18.8 40,480 14,642 Uganda 20.8 17.8 29,928 9,752 Vietnam 9.6 7.8 12,479 - Zambia 17.3 14.8 9,597 1,816 Zimbabwe 23.7 16.0 7,113 1,778 TOTAL 504,704 2 UN IGME stillbirth estimates are developed in consultation with countries and are based on available country-level data sources including registration systems (e.g., CRVS, birth or death registries, or HMIS), household surveys (e.g., DHS), or from population-based studies (1). 3 Current DHS questionnaires significantly underestimate stillbirths (14,23). 4 Assuming countries already below 12 SBR stay at or below current level. GFF ROADMAP FOR IMPROVING MONITORING AND DATA SYSTEMS TO COUNT AND ACCOUNT FOR STILLBIRTHS 5 What are the challenges to reporting stillbirths? — including Health Management Many data systems in LMIC ­­ Information Systems (HMIS), Civil Registration and Vital Statistics (CRVS) systems, perinatal death5 audits linked to maternal and perinatal death surveillance and response (MPDSR), and population-based household surveys such as Demographic Health Surveys (DHS) or Multiple Indicator Cluster Surveys (MICS) — do not sufficiently report stillbirths. There are several reasons for this at the different health systems levels (see Table 2 for more information): 1 National and sub-national levels – Limited awareness of the burden of stillbirths; disparate country-level standards and guidance on the definition of stillbirths and standards of measurement6; lack of legal frameworks requiring perinatal death notification and notification/registration of stillbirths; limited government financing to monitor stillbirths; and challenges with recording stillbirths and data systems for routine reporting; surrounding stillbirths and reporting of stillbirths. Health facility and community levels – Non-standardized health facility 2 registers; low levels of community-based reporting; misclassification of stillbirths and inaccurate reporting due to inadequacy of health workers’ skills, lack of time, and/or stigma and fear of blame associated with stillbirths/lack of legal frameworks to protect health care workers in these deaths. Individual-level – Social and religious norms and stigma surrounding 3 stillbirths and reporting of stillbirths. The perinatal deaths are those occurring in the perinatal period [from 22 completed weeks of gestation and ending 5 7 completed days after birth (i.e., includes days 0-6 after birth)]. Therefore, perinatal deaths include both early and late stillbirths and early neonatal deaths. Many countries use different definitions for stillbirths, however, for international comparisons, the World Health 6 Organization (WHO) through the 10th revision of the International Classification of Diseases (ICD-10) recommends the following definition “a fetal death occurring at >=1000 grams, or if birthweight is not available at >=28 weeks of gestation, or>=35 cm crown-heel length.” However, for the most recent UN estimates and from ICD-11 onwards the >=28 weeks gestational age definition is used for international comparison, with the >=1000 gram threshold only if gestational age is not available (1). 6 What recent changes are helping the reporting of stillbirths? The good news is that many countries and global organizations are pushing to strengthen the counting of stillbirths. Despite there being no specific target for stillbirths in the Sustainable Development Goals (SDG), all the GFF-supported countries have endorsed the ENAP target to achieve 12 stillbirths or fewer per 1,000 total births by 2030. ENAP also provides countries with a changed to collect a woman’s full pregnancy roadmap for ending preventable stillbirths history, rather than a full birth history as and newborn deaths (2). The UN Global was done in the past, which improves the Strategy for Women’s, Children’s and reporting of stillbirths (5). Global guidance Adolescents’ Health (2016-2030) includes has been developed on improving the stillbirths in its vision statement (3). Stillbirths registration of live births, stillbirths, and are one of the “100 Core Health Indicators” deaths (6). Various tools, digital collection of the WHO and Every Newborn core forms, automated analyses, training, and indicators (2,4). The UN IGME generates reports are available to improve HMIS stillbirth estimates every two years. performance for stillbirth data collected at the health facility up to sub-national and In addition, there has been greater national levels (7). Also, guidance for attention paid to the inclusion of stillbirths conducting perinatal death surveillance in HMIS and population-based surveys: and response in clinical and policy Based on research evidence, the DHS settings is available from the WHO (8,9). core survey module (DHS-8) was recently GFF ROADMAP FOR IMPROVING MONITORING AND DATA SYSTEMS TO COUNT AND ACCOUNT FOR STILLBIRTHS 7 What is the current state of stillbirth reporting in GFF-supported countries? Across the 37 GFF-supported countries, report stillbirths in their HMIS (10). Fewer only a fifth have defined stillbirth targets than 40% have a perinatal death review in their national RMNCAH-N plans (2) and system (2). Though this analysis (Figure 2) fewer than a third are required by law to is only limited to those countries currently register stillbirths in their CRVS systems supported by the GFF, these shortfalls are (Figure 2). Around 40% do not currently likely to be typical of other LMIC as well. Figure 2. Number of GFF-supported countries with defined stillbirth targets and stillbirth data collection systems Defined stillbirth target 7 22 8 Required by law to register stillbirths in CRVS 26 11 Stillbirths reported in HMIS-DHIS2 15 22 Perinatal death review system in place 12 11 14 0 5 10 15 20 25 30 35 40 no information no yes Note: The values are based on secondary data sources published since 2017. 8 How can countries improve the monitoring and reporting of stillbirths? Table 2. CHALLENGES RECOMMENDED ACTIONS National- and sub-national Strategies, legal frameworks, and funding • Thedefinition of stillbirth is • Ensure that the definition of stillbirths is aligned with not aligned with international international standards. While countries can define standards and is not used stillbirths as they want depending on their context, at consistently in all data a minimum, all countries should report stillbirths at reporting tools. >= 28 weeks gestation for international comparison. Where feasible, also collect data for early gestation stillbirths (>=22 - <28 completed weeks) and report these separately to those >=28 weeks (9). • Lack of legal frameworks • Institutelegal framework, safeguards, or protocol for requiring perinatal death perinatal death notification. notification and civil registration legislation to include the registration of stillbirths. • Limited government • Increasecountry investments in stillbirth monitoring financing to monitor and national and subnational data collection and stillbirths and improve system reforms, including financing to strengthen data systems. CRVS and MPDSR systems. • Limitedawareness of the • Increase awareness and political commitment to the importance of stillbirth data importance of stillbirth reporting through advocacy, as a marker of equity and training, and targeted education (11). the quality of antenatal and intrapartum care. • Lack of clear and consistent • Support the development of a national strategy that guidelines on the definition includes the definition and goals for preventing stillbirths of stillbirths and standards and how stillbirths should be reported. for measurement. GFF ROADMAP FOR IMPROVING MONITORING AND DATA SYSTEMS TO COUNT AND ACCOUNT FOR STILLBIRTHS 9 CHALLENGES RECOMMENDED ACTIONS Actionable information systems HMIS • Some countries do not record or • Record stillbirths in HMIS/DHIS2 using the standard report stillbirth via HMIS/DHIS2 WHO minimum perinatal data set (8,12). even if there is a policy to do so. • Include tracking of early stillbirths (fetal deaths 22-27 weeks) and late gestation stillbirths (fetal deaths>=28 weeks) in DHIS-2. • Many exclude home births and • Extend the reach of HMIS systems to track live births births in private health facilities. and stillbirths occurring in private sector facilities and at home. • Improve interoperability between health facility and community information systems to capture stillbirths. • Link verbal autopsy from home births with MPDSR systems. CRVS • Recording stillbirth data is • Where necessary, develop/amend a costed national generally not included in CRVS CRVS strategy and implementation plan, including legal frameworks or CRVS reporting stillbirths. strengthening efforts.7 • Low coverage of CRVS in LMICs, • Collectstillbirth data in CRVS and produce vital statistics. particularly for rural populations • Expand access to computerized CRVS systems. or some marginalized groups. • Introduce innovations to improve birth registration in countries with low national and sub-national coverage through incentives to community-level staff. Perinatal death reviews • Perinatal death reviews are not • MPDSR should not be limited to maternal and neonatal as widely implemented as deaths but should routinely include the review of stillbirths. maternal death reviews. • As recommended by the WHO, ensure national prioritization of prevention of maternal and perinatal deaths and conducting a “No Name, No Blame, and No Shame” MPDSR through a national MPDSR policy and guidelines, a legal framework for notifying deaths and involving communities and othersectors, availability of MPDSR tools, nurturing team relationships and a culture of quality improvement among those who participate in the audit, and regular audit meetings (9,13). • Failure to move to full- • Define common/core measures for monitoring MPDSR scale national and sub- at the health facility, district/regional, and national levels national implementation to better track implementation by all programs at all of MPDSR. levels and to facilitate learning. • Establish MPDSR committees at provincial/district levels and align their roles in information sharing and communication • Coordinate maternal and perinatal death reviews and activities, including how to prioritize the review of perinatal deaths. • Integrate MPDSR into routine monitoring systems to standardize the process and accountability within both the public and private sectors. Stillbirths are not included in Civil Registration as they do not have a legal identity – but information on stillbirths 7 can be collected in a ‘fetal death’ or ‘stillbirth’ register which can be used for the purposes of vital statistics. 10 CHALLENGES RECOMMENDED ACTIONS Population-based household surveys • Few country large-scale • Ensure the use of more reliable measures of stillbirths retrospective household surveys (i.e., for household surveys using a full pregnancy history (e.g., DHS, MICS) report on instead of a full birth history) (11,14). stillbirths and/or use a woman’s • Add questions on gestational age and birthweight for all full pregnancy history births, vital status at birth for all stillbirths and neonatal (FPH) method. deaths, and sex of stillborn baby (11). • Most marginalized/vulnerable • Include the most vulnerable in household surveys: groups may not be fully women <15 years old, never married, and living represented (e.g., in in fragile settings (11). fragile settings). • Data quality accuracy can be • Ensure sufficient quality and length of interviewer affected by length of interviewer training, including building rapport with respondents training, socio-cultural beliefs, to earn a woman’s trust and interviewer’s understanding and/or women not knowing their of and respect for local culture (15) stillborn baby’s gestational age • Address misreporting by raising awareness and public or birthweight. education about stillbirth to reduce the stigma experienced by women. Promote respectful maternity care agenda (16). Data use and interoperability • Data reports are not always • Atthe national level, use data collected in data systems shared with health care workers detailed above to track progress toward the ENAP or higher-level data systems. target of 12 stillbirths or fewer per 1,000 total births in every country by 2030. Report and review stillbirth of bidirectional • Lack data and neonatal deaths at the facility and district HMIS feedback. levels, monitoring for potential misclassification (1). Disaggregate reported stillbirth rates at all levels of care, equity groupings, and for public and private facilities. • Different data systems are often • Look for opportunities to integrate stillbirth reporting not interlinked and interoperable. in existing systems (e.g., CRVS system, MPDSR, HMIS, and at the community level) (if stillbirth reporting is not routine). Improve interoperability between different data platforms to streamline data systems and increase efficiency. data are not always • Stillbirth • Ensure that stillbirth data are accessible at all health used for action at both national systems levels through dashboards, monthly reports, and sub-national levels. and annual reports and that they are understood, valued, and acted upon (11). • Widespread use of macerated • Disaggregateby antepartum/ intrapartum and not and fresh stillbirth.8 fresh/macerated. GFF ROADMAP FOR IMPROVING MONITORING AND DATA SYSTEMS TO COUNT AND ACCOUNT FOR STILLBIRTHS 11 CHALLENGES RECOMMENDED ACTIONS Health facilities/communities Health and community registers • Facility registers do not always • Ensure standardized and streamlined registers for countries record key perinatal outcome using either paper or electronic systems. Involve health information. They can be very care workers in designing the changes to existing registers complex, not streamlined, to meet their needs for clinical decision making and data too long, and/or provide reporting. Move from classifying stillbirths from fresh and vague instructions. macerated to using the presence of a fetal heart rate on admission for delivery to classify stillbirths as antepartum or intrapartum. • Registers do not always use • Recordstillbirths using the standard WHO minimum the WHO standardized system perinatal data set (8,12). for classifying stillbirths and • StandardizeHMIS systems flow to include registers, forms, neonatal deaths. and electronic HMIS (e.g., DHIS-2). • Summary forms/ tally sheets used to aggregate data not aligned with registers. • Community-based births • Improve community-based reporting through community are often not recorded, sources. Explore integrating the reporting of stillbirths with especially stillbirths. other existing initiatives, such as community-based maternal death surveillance and response systems, integrated disease surveillance and response systems, or ongoing public health campaigns (e.g., vaccination). • Misclassification between stillbirth • Traincommunity informants on how and neonatal death is common to identify and report stillbirths (8). through community informants. • Exploredifferent modes of data collection for births occurring outside of the health system, including pregnancy registers and mhealth innovations (11). Health worker competency, training, and supervision • Difficulty in correctly classifying • Conduct and improve pre-service and in-service training stillbirths, including those that on the importance of accurate recording and registering are antepartum and intrapartum. every birth and death, including stillbirths; timely newborn • Lack of health worker training care, recognizing signs of life and neonatal resuscitation; in HMIS competencies. recording fetal heart rate on admission; accurate gestational age assessment for both live and stillborn babies; build • Inadequate technical skills health worker skills to implement MPDSR processes; record and knowledge to complete stillbirths by antepartum/ intrapartum and not fresh/ MPDSR processes. macerated; socio-cultural norms regarding stillbirths, and communicating about the stillborn baby to bereaved women and families in a sensitive manner (11,17). The assumption is that a “macerated” stillbirth is when the fetus died more than 12 hours prior to childbirth and “fresh” 8 less than 12 hours prior to childbirth. “Macerated” thus implies antepartum stillbirths and “fresh” intrapartum stillbirths. This classification does not match observed data and should be discontinued (24). 12 CHALLENGES RECOMMENDED ACTIONS resulting from • Misclassification • Institutea health facility “No Name, No Blame, and stigma and fear of blame No Shame” reporting process for stillbirths as outlined associated with stillbirths. by WHO for MPDSR reporting (see MPDSR section above) (9,13). • Length of time to fill • Conduct health facility analyses of data recording out registers for busy roles and practices and data flows. Determine who health workers. should be responsible for data entry and allocate necessary resources. • Explore use of digital technology and mobile apps for recording and reporting stillbirths. motivation for • Low • Value health care workers’ routine data recording. HMIS tasks. • Minimal supervision on how • Providesupportive supervision to improve to fill out the registers and data quality. data quality. • Improve data quality through cycles of audit and feedback, comparing HMIS monthly reports to labor ward register data (18). Availability of resources • Shortage of human and • Ensure sufficient hardware for data entry, including material resources at paper registers, summary forms, computers, internet, health facilities, including servers, and power backup. Explore data collection HMIS logistics. systems that function in settings with intermittent or limited electricity (11). • Ensure functional and suitable digital weighing devices for every birth (19). • Explore innovations to improve the measurement of gestational age and birthweight (11). • Provide guidelines and job aids for weighing live and stillborn babies at birth. Families/Individuals and religious norms and • Social • Provide improved communication between families and stigma surrounding stillbirths health care providers for improved care and reporting and reporting of stillbirths. of stillbirths (20). • Provide bereavement support for families, communities, and caregivers affected by stillbirths(20). Conduct implementation research on this understudied topic in LMICs. • Address misreporting by raising awareness and public education about stillbirth to reduce the stigma experienced by women. Promote respectful maternity care agenda (16). GFF ROADMAP FOR IMPROVING MONITORING AND DATA SYSTEMS TO COUNT AND ACCOUNT FOR STILLBIRTHS 13 How can countries leverage the GFF partnership to improve stillbirth reporting and prevention? Through a country-led process, there is an opportunity to improve the prevention and reporting of stillbirths in GFF partner countries. The list below captures areas where work is ongoing through the partnership and where future efforts could be focused. RMNCAH-N investment cases Data for decision making • Government and country platform • Stillbirths are included in data reporting stakeholders ensure that CRVS for the GFF data portal. components for timely and accurate data • GFF works with other development and on vital events, including stillbirths, are financing partners in countries to adopt included in RMNCAH-N investment cases. the same stillbirth indicators across all • MOH conducts assessments on stillbirth relevant health sector projects. data sources. • GFF supports World Bank teams to • Government (or country platform) include stillbirths prevented as an prioritizes activities to improve the impact indicator in projects that support availability, quality, and use of data on high-quality intrapartum care; stillbirth stillbirths in national reporting systems. reporting in projects that support strengthened HMIS; and stillbirth GFF Country Platform inclusion in MPDSR where this is part of an M&E framework. • Stakeholders raise awareness of stillbirth • GFF supports World Bank teams for reporting as a marker of poor maternal health and low access and coverage of the inclusion of stillbirths prevented as quality antenatal and intrapartum care; a disbursement linked indicator (DLI) the importance of stillbirth prevention; or result (DLR) in Program for Results addressing stigma and blame associated (PforR) operations, given that stillbirths with stillbirths. are an indicator of poor quality of antenatal and intrapartum care and • Government forms a group of champions service delivery. in-country, including the private sector, who will advocate for stillbirth prevention and reporting at national and sub- Health financing and health national levels and reaching the ENAP service quality stillbirth target of 12 stillbirths or fewer • Government and country stakeholders per 1,000 total births. build on existing in-country health • Stakeholders develop an implementation financing work to ensure adequate plan that outlines the roles and domestic financing to achieve responsibilities for implementation the following: and accountability for results for the a) Improve the utilization of facility- investment case. based health care services for antenatal and intrapartum care; 14 b) Improve clinical practice and quality birth and death registration data, of services provided during antenatal submission mechanisms for vital care and labor and delivery; and registration records, and demand c) Sustain the supply of quality and utilization of CRVS data. RMNCAH-N products and Assisting countries in strengthening • technologies, including systems for existing CRVS systems to capture all demand forecasting and procurement life events, including fetal deaths; for essential equipment (including building electronic systems for infant weighing scales). sustainable and efficient delivery • In results-based financing (RBF) of CRVS services; and linking to platforms, government and country other data-collection systems. stakeholders improve the quality • Providing TA for countries to change of HMIS, including the reporting labor and delivery registers and of stillbirths, through verification HMIS-DHIS2 reporting systems to mechanisms and use disaggregated include recording gestational age, data (equity) for course correction presence of fetal heart sound during every quarter. labor, and birth outcome for each birth and death (2). Analytics, innovation, and • Conduct in-country implementation implementation research research on interventions to standardize labor ward register design and improve When requested by the Government, register layout, column labeling, and cell GFF and development partners can coding to see whether it improves data provide technical support to: quality (18). • Report and estimate stillbirth • Conduct in-country implementation prevention potential. research to streamline HMIS data • Ensure that guidelines and legal systems, including registers and case frameworks incorporate international notes, to improve real-time decision- stillbirth definitions and standards for making (e.g., better classification measurement and reporting. of stillbirths) while reducing the documentation burden on health • Provide funding and technical assistance workers (3). (TA) to identify and cost the scaled use • Conduct assessment of the impact of innovations (to address key constraints in identifying, recording, and reporting on quality of stillbirth reporting of stillbirths at the community and health a two-way data flow from the labor facility levels) (11, 21). ward registers into the HMIS and with feedback returning to the health facility • Ensure that stillbirth indicators are to strengthen health care workers’ integrated into existing reporting performance (18). systems, including digital HMIS • While not the focus of this report, platforms; are interoperable; and are accessible at all health systems TA should not stop at improving the levels through dashboards with routine monitoring and classification of stillbirths data review. Support, for example, but can also extend to responsiveness can include: and stillbirth prevention. TA can include quality and respectful antenatal care and • Analyzing existing CRVS systems screening for infections; intermittent to identify gaps, including indicators preventive treatment of malaria for (reporting of fetal deaths), birth and pregnant women; and improved quality fetal death registration coverage, of care during birth, including the birth and death registration sites implementation of the 2020 WHO Labor or reporting modalities, quality of Care Guide. GFF ROADMAP FOR IMPROVING MONITORING AND DATA SYSTEMS TO COUNT AND ACCOUNT FOR STILLBIRTHS 15 Conclusion Many national data systems in LMIC do not record stillbirths, or the stillbirth data is unusable due to non-standard definitions, inaccurate classification, or underreporting. The 2020 Report of the UN IGME called stillbirths a “neglected tragedy” because they are unnecessary, unseen, unrecognized, underprioritized, and underfinanced (1,22). As a first step, stillbirths must be counted accurately. The GFF can support governments in improving stillbirth reporting and responsiveness through technical support for improved HMIS and explicitly addressing preventable stillbirths within co-funded projects. Pregnant woman and a community health worker during a health checkup in Niger. Photo: © Olivier Girard / The Global Financing Facility GFF ROADMAP FOR IMPROVING MONITORING AND DATA SYSTEMS TO COUNT AND ACCOUNT FOR STILLBIRTHS 17 References 1. UNICEF. A neglected tragedy. The global burden of stillbirths. Report of the UN Inter-agency Group for Child Mortality Estimation, 2020. New York, NY; 2020. 2. WHO and UNICEF. Reaching the every newborn national 2020 milestones: country progress, plans and moving forward. Geneva; 2020. 3. Every Woman Every Child. The Global Strategy for Women’s Children’s and Adolescents’ Health (2016-2030). 2016. 4. Frøen JF, Lawn JE, Heazell AEP, Flenady V, Bernis L de, Kinney M V, et al. 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Peven K, Day LT, Ruysen H, Tahsina T, Kc A, Shabani J, et al. Stillbirths including intrapartum timing: EN-BIRTH multi-country validation study. BMC Pregnancy Childbirth. 2021;21(Suppl 1):1–18. Maternity Hospital, in Freetown Sierra Leone. 18 Photo: © Dominic Chavez / World Bank GFF ROADMAP FOR IMPROVING MONITORING AND DATA SYSTEMS TO COUNT AND ACCOUNT FOR STILLBIRTHS 19 © 2022 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of the Global Financing Facility (GFF) Secretariat at the World Bank, with contributions from UNICEF, WHO, and the London School of Hygiene and Tropical Medicine. 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