Stillbirth and Neonatal Death

Authored by , Reviewed by Dr John Cox | Last edited | Meets Patient’s editorial guidelines

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  • Stillbirth: the death of a baby before or during birth after 24 weeks of gestation in the UK. (The World Health Organization (WHO) definition is after 28 weeks.)
  • Neonatal death: the death of a baby within the first 28 days of life.
  • Perinatal mortality: stillbirths plus early neonatal deaths (under 7 days). (This is a universal definition.)
  • Stillbirth rate: the number of stillbirths per thousand total births.
  • Low birth weight: weight at birth under 2500 g. (The universally accepted definition.)

According to the Office for National Statistics (ONS) in England and Wales, there were 3,558 stillbirths in 2012 - a stillbirth rate of 4.9 per 1,000 live births. This had dropped from 5.3 in 2011. There were 2,042 neonatal deaths - a rate of 2.8 per 1,000 live births - of which 2.2 were early neonatal deaths. Both rates have continued to fall over a period of two decades, and perinatal mortality rates have fallen by a third since 1982. It is felt that improvements in general healthcare, midwifery and neonatal intensive care are bringing about the gradual decline in deaths.

Worldwide figures are higher. A recent WHO survey gives the stillbirth rate (although note the variable definition affects numbers) as 17.7 across 29 countries, and the early neonatal death rate as 8.4.[2]

  • Fetal growth restriction:
    • The biggest risk factor for stillbirth.
    • A 2012 study of stillbirths in England showed the risk to be significantly higher where the growth restriction was not detected antenatally, suggesting this as an important avenue for reducing stillbirth rates in the future.[3] It concluded strategy should focus on improving antenatal detection of growth restriction, and subsequent management of pregnancy and delivery.
  • Preterm birth:[4]
    • This is the biggest risk factor for neonatal death.
    • Obstetric and neonatal care can have a major impact on death rates of preterm babies. (For example, antenatal steroids for women in preterm labour, and advanced neonatal intensive care which may not be available in some parts of the world.)
  • Age of mother:
    • The rate of neonatal death is higher in babies born to women under the age of 25, and women over the age of 40. In the UK, women aged 40 or over are 1.3 times more likely to have a neonatal death compared to women aged 25-29.[5]
    • Stillbirth rates increase with advancing maternal age. The rate increases from 4.6 in the 25- to 29-year age group to 7.6 for mothers aged 40 or over.
    • Systematic reviews have confirmed advancing maternal age as a risk factor.[6]However, the most recent UK-based study of risk factors did not bear this out.[3] This may have been because babies with congenital abnormalities, known to occur more often in pregnancies of older women, were excluded from the study.
    • Cochrane reviews have demonstrated that induction of labour in women going past term reduces the risk of perinatal death.[7]National Institute for Health and Care Excellence (NICE) guidelines therefore recommend that women going past their term dates be induced at 41 weeks.[8] There is discussion ongoing about whether older women should be offered induction earlier, at 39-40 weeks of gestation, in order to reduce the risk of perinatal deaths.[5]
  • Maternal health:
    • Obesity: a mother's BMI ≥30 increases risk of stillbirth and neonatal death, and possibly as much as doubles it.[3, 9, 10]
    • Smoking: smoking causes increased risk of stillbirth where it leads to growth restriction but not as an independent factor.[3] It increases the risk of neonatal death in a number of ways, including adding to the risk of preterm birth.
    • Chronic diseases - eg, diabetes, renal failure, hypertension, haemoglobinopathy, rhesus disease, thrombophilias, antiphospholipid syndrome. Pre-existing diabetes increases risk of stillbirth significantly, whereas gestational diabetes does not appear to increase risk.[3]
    • Infection - eg, erythema infectiosum, varicella, measles.
    • Substance abuse, especially cocaine.
    • A history of mental health problems increases risk.
  • Obstetric complications:
    • Pre-eclampsia and antenatal haemorrhage increase the risk of stillbirth.
    • Intrapartum complications, such as malpresentation or obstructed labour, confer high risk of perinatal mortality.
  • Multiplicity of pregnancy:
    • The risk of perinatal death is 2-5 times higher for multiple pregnancies compared to singleton pregnancies.[11]
    • Stillbirth and neonatal death rates are significantly higher in monochorionic twins than in dichorionic twins (44.2 vs 12.2 per 1,000 births in the North England study of twin and multiple pregnancy).[12]
  • Parity:
    • Nulliparous women have a higher risk of stillbirth than multiparous women across all ages.[5]
    • Third and subsequent pregnancies have a higher risk than second pregnancies.[3]
  • Congenital abnormality:
    • Increases risk of stillbirth and neonatal death. In the main not a potentially avoidable risk factor so it is often left out of analyses.
    • Fewer than 10% of stillbirths are caused by congenital abnormalities.[13]
  • Low birth weight:
    • Strongly linked with neonatal death and infant mortality.
    • Inter-related with other factors, such as prematurity, multiple pregnancy, smoking.
    • In 2012, there were 173 deaths per 1,000 live births for very low birth weight babies (<1500 g), 35.2 per 1,000 for low birthweight babies (<2500 g), compared to 1.3 per 1,000 for normal birth weight babies. These ONS figures are for infant mortality as a whole, ie deaths up to the first year of life, but neonatal deaths show a similar trend.[1]
  • Region of maternal residence:
    • Most regions in the UK show fluctuations in stillbirth rates.
    • In 2012, rates of both stillbirths and neonatal deaths were highest in the West Midlands and lowest in the South of England.[1]
  • Social factors:[3]
    • Lack of employment and high deprivation index increase risk of stillbirth.
    • Later antenatal booking appointments past 13 weeks was associated with increased risk of stillbirth.
  • Ethnicity:
    • African and African-Caribbean women have significantly higher risk of stillbirth. Risk is also increased in Indian mothers and first-generation migrants from Pakistan.[3]
  • Sex:
    • Trends show that stillbirth rates are slightly higher among males compared to females.

Causes of neonatal death

  • Prematurity (causing particularly respiratory and neurological conditions)
  • Congenital abnormality
  • Obstetric complications
  • Infection

Causes of stillbirth

  • Congenital abnormality
  • Haemorrhage, during pregnancy or labour
  • Placental insufficiency
  • Placental abruption
  • Pre-eclampsia
  • Obstetric complications
    • Spontaneous premature labour
    • Premature rupture of membranes
    • Polyhydramnios
    • Oligohydramnios
    • Intrapartum asphyxia
    • Birth trauma
  • Cord prolapse
  • Intra-uterine growth restriction
  • Liver disease - obstetric cholestasis, intrahepatic cholestasis of pregnancy
  • Diabetes
  • Infections during pregnancy

In England the latest report into causes of perinatal death was the Centre for Maternal and Child Enquiries (CMACE) report of 2009, published in 2011.[14]This long-term audit has been now passed on to 'Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries in the UK' (MBRRACE UK), and there are currently no more recent reports. The classification system for causes of death changed in 2008, in an attempt to reduce the number of previously "unclassifiable" deaths.

In the 2011 UK report, 28% of stillbirths remained unexplained. Placental conditions caused 12% of stillbirths, antepartum/intrapartum haemorrhage 11%, and major congenital abnormality 9%. 8% of stillbirth deaths occurred during labour or delivery.

For neonatal deaths, 27% were from obstetric factors, of these spontaneous premature labour being the most common. 25% were due to congenital abnormality, and 10% due to infection. A further neonatal classification system uses the specific cause of death in premature babies, the most common causes being respiratory disorders (of which the most common was severe pulmonary immaturity), followed by neurological disorders (particularly hypoxic-ischaemic encephalopathy and intraventricular/periventricular haemorrhage).

Reports for Scotland, Wales and Northern Ireland have continued. Differing classification systems are used. In Scotland, the 2011 report showed for stillbirths the most common cause was fetal growth restriction (38%), followed by APH (15%) and congenital abnormality (12%). Conditions associated with prematurity were the most common cause of neonatal death (41%) followed by congenital abnormality.[15]In the 2012 report for Wales,  42% of stillbirths are classified as unexplained, with APH the most common classifiable cause (13.3%), and congenital abnormality next (6.6%). For neonatal deaths, preterm birth caused 37%, congenital abnormality 22% and infection 14.5%.The 2012 report for Northern Ireland gives placental conditions and congenital abnormalities as the most common cause for stillbirths.

  • The mother may be aware of a decrease in fetal movements in many cases of stillbirth.
  • Other stillbirths may be discovered at the routine antenatal check.
  • An ultrasound examination is used to confirm that the fetus has died; this is seen as lack of a visible heartbeat.
"The quality of care that bereaved families receive when their baby dies has long-lasting effects. Good care cannot remove parents' pain and grief, but poor care can and does make things much worse."[18]

Where the death of the baby is diagnosed antenatally, labour is induced using prostaglandins administered vaginally. This does not need to be immediate, but should happen within 2-3 days.

The mother will need to have:

  • Blood pressure checked.
  • Urine tested for protein.
  • Temperature taken.
  • Cervical and vaginal swabs for MC&S.
  • Blood taken for FBC, clotting screen (including antiphospholipid antibody and thrombophilias), Kleihauer test, HbA1c, cultures (Listeria spp.) and serology (parvovirus B19, toxoplasmosis and cytomegalovirus) and cytogenetics.

Bereavement care:

  • Stillbirth is a devastating event for the parents and their family.
  • The mother and father should be given time and space for reflection in a suitable environment away from the normal postnatal ward.
  • They should be allowed to dress and spend time with their child. They may wish to take photos and make some memories to take with them:
    • Most hospitals have protocols in place for dealing with stillbirths - eg, wrap the baby, offer to the mother to hold, and take photographs, hair and palm prints.
  • They will need to collect their belongings and may want to make funeral arrangements. Most hospitals can offer funeral services, if required.
  • Hospital counsellors and chaplains may provide comfort to families of stillborn infants.
  • All maternity units should have specially trained bereavement midwives.
  • Discuss the need, and arrange consent, for post-mortem examination.
  • Inform GP practice, so that GP and practice staff are aware of the death, and so GP can provide support where appropriate.
  • Stillbirth registration began on 1 July 1927, to help protect infant life.
  • As well as being an important source of historical and statistical information, it also gives parents the opportunity to have their child officially acknowledged and to give him or her names if they wish to, which can help with grief.
  • Stillbirths in England and Wales must normally be registered at the hospital or local register office within 42 days of the stillbirth, but cannot be registered more than 3 months after its occurrence.[19]
  • To register the stillbirth, the medical certificate of stillbirth issued by the doctor or midwife present at the time is required.
  • The registrar will issue a certificate for burial or cremation of the stillborn infant. This certificate is usually passed to the funeral director who will make the arrangements.
  • Following a stillbirth or neonatal death, parents are entitled to maternity leave, paternity leave, statutory maternity pay/allowance or statutory paternity pay as relevant.

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Further reading and references

  1. Child mortality statistics: Childhood, infant and perinatal, 2012; Office for National Statistics (ONS)

  2. Vogel J, Souza J, Mori R, et al; Maternal complications and perinatal mortality: findings of the World Health Organization Multicountry Survey on Maternal and Newborn Health. BJOG. 2014 Mar121 Suppl s1:76-88. doi: 10.1111/1471-0528.12633.

  3. Gardosi J, Madurasinghe V, Williams M, et al; Maternal and fetal risk factors for stillbirth: population based study. BMJ. 2013 Jan 24346:f108. doi: 10.1136/bmj.f108.

  4. Lawn JE, Kinney MV, Belizan JM, et al; Born Too Soon: Accelerating actions for prevention and care of 15 million newborns born too soon. Reprod Health. 2013 Nov 1510(Suppl 1):S6. Epub 2013 Nov 15.

  5. Induction of labour at term in older mothers; Royal College of Obstetricians and Gynaecologists, February 2013

  6. Flenady V, Koopmans L, Middleton P, et al; Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet. 2011 Apr 16377(9774):1331-40. doi: 10.1016/S0140-6736(10)62233-7.

  7. Gulmezoglu AM, Crowther CA, Middleton P, et al; Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev. 2012 Jun 136:CD004945.

  8. Induction of labour; NICE Clinical Guideline (July 2008 - currently under review)

  9. Cresswell JA, Campbell OM, De Silva MJ, et al; Effect of maternal obesity on neonatal death in sub-Saharan Africa: multivariable analysis of 27 national datasets. Lancet. 2012 Oct 13380(9850):1325-30. doi: 10.1016/S0140-6736(12)60869-1. Epub 2012 Aug 9.

  10. Kristensen J, Vestergaard M, Wisborg K, et al; Pre-pregnancy weight and the risk of stillbirth and neonatal death. BJOG. 2005 Apr112(4):403-8.

  11. Skeie A, Froen JF, Vege A, et al; Cause and risk of stillbirth in twin pregnancies: a retrospective audit. Acta Obstet Gynecol Scand. 2003 Nov82(11):1010-6.

  12. Glinianaia SV, Rankin J, Sturgiss SN, et al; The North of England Survey of Twin and Multiple Pregnancy. Twin Res Hum Genet. 2013 Feb16(1):112-6. doi: 10.1017/thg.2012.65. Epub 2012 Oct 9.

  13. SANDS - Stillbirth and Neonatal Death Society

  14. Perinatal Mortality 2009; Centre for Maternal and Child Enquiries (CMACE), March 2011

  15. Perinatal and Infant mortality and morbidity report (year ending December 2011); Information Services Division (ISD) Scotland, March 2013

  16. Professionals information; Stillbirth And Neonatal Death Society (SANDS)

  17. Register a stillbirth; GOV.UK