Global, regional, and national stillbirths at 20 weeks' gestation or longer in 204 countries and territories, 1990-2021: findings from the Global Burden of Disease Study 2021

Background Stillbirth is a devastating and often avoidable adverse pregnancy outcome. Monitoring stillbirth levels and trends-in a comprehensive manner that leaves no one uncounted-is imperative for continuing progress in pregnancy loss reduction. This analysis, completed as part of the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021, methodically accounted for different stillbirth definitions with the aim of comprehensively estimating all stillbirths at 20 weeks or longer for 204 countries and territories from 1990 to 2021. Methods We extracted data on stillbirths from 11 412 sources across 185 of 204 countries and territories, including 234 surveys, 231 published studies, 1633 vital statistics reports, and 10 585 unique location-year combinations from vital registration systems. Our final dataset comprised 11 different definitions, which were adjusted to match two gestational age thresholds: 20 weeks or longer (reference) and 28 weeks or longer ( for comparisons). We modelled the ratio of stillbirth rate to neonatal mortality rate with spatiotemporal Gaussian process regression for each location and year, and then used final GBD 2021 assessments of fertility and all-cause neonatal mortality to calculate total stillbirths. Secondary analyses evaluated the number of stillbirths missed with the more restrictive gestational age definition, trends in stillbirths as a function of Socio-demographic Index, and progress in reducing stillbirths relative to neonatal deaths. Findings In 2021, the global stillbirth rate was 23 center dot 0 (95% uncertainty interval [UI] 19 center dot 7-27 center dot 2) per 1000 births (stillbirths plus livebirths) at 20 weeks' gestation or longer, compared to 16 center dot 1 (13 center dot 9-19 center dot 0) per 1000 births at 28 weeks' gestation or longer. The global neonatal mortality rate in 2021 was 17 center dot 1 (14 center dot 8-19 center dot 9) per 1000 livebirths, corresponding to 2 center dot 19 million (1 center dot 90-2 center dot 55) neonatal deaths. The estimated number of stillbirths occurring at 20 weeks' gestation or longer decreased from 5 center dot 08 million (95% UI 4 center dot 07-6 center dot 35) in 1990 to 3 center dot 04 million (2 center dot 61-3 center dot 62) in 2021, corresponding to a 39 center dot 8% (31 center dot 8-48 center dot 0) reduction, which lagged behind a global improvement in neonatal deaths of 45 center dot 6% (36 center dot 3-53 center dot 1) for the same period (down from 4 center dot 03 million [3 center dot 86-4 center dot 22] neonatal deaths in 1990). Stillbirths in south Asia and sub-Saharan Africa comprised 77 center dot 4% (2 center dot 35 million of 3 center dot 04 million) of the global total, an increase from 60 center dot 3% (3 center dot 07 million of 5 center dot 08 million) in 1990. In 2021, 0 center dot 926 million (0 center dot 792-1 center dot 10) stillbirths, corresponding to 30 center dot 5% of the global total (3 center dot 04 million), occurred between 20 weeks' gestation and 28 weeks' gestation, with substantial variation at the country level. Interpretation Despite the gradual global decline in stillbirths between 1990 and 2021, the overall number of stillbirths remains substantially high. Counting all stillbirths is paramount to progress, as nearly a third-close to 1 million in total-are left uncounted at the 28 weeks or longer threshold. Our findings draw attention to the differential progress in reducing stillbirths, with a high burden concentrated in countries with low development status. Scarce data availability and poor data quality constrain our capacity to precisely account for stillbirths in many locations. Addressing inequities in universal maternal health coverage, strengthening the quality of maternal health care, and improving the robustness of data systems are urgently needed to reduce the global burden of stillbirths.