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Fetal death and stillbirth: Incidence, etiology, and prevention

Ruth C Fretts, MD, MPH
Catherine Spong, MD
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG


The terms fetal death, fetal demise, stillbirth, and stillborn all refer to the delivery of a fetus with no signs of life. The terms will be used interchangeably in this topic review. It should be noted that parent groups prefer the term stillbirth to the other terms. The ability to call a fetal loss a stillbirth is important to parents, in part because birth and death certificates are not generated after a miscarriage. In addition, parents report they receive less grief support after a miscarriage than after a stillbirth and less acknowledgement of the death of their child.

The incidence and etiology of fetal death, as well as strategies for prevention, will be reviewed here. Diagnosis and management of fetal demise, pathological evaluation of stillborns, and parental support and counseling are discussed separately:

(See "Evaluation of stillbirth".)

(See "Fetal death and stillbirth: Maternal care".)


Overview — Terminology regarding fetal death and stillbirth is complicated and confusing for several reasons, including:

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Literature review current through: Nov 2017. | This topic last updated: Nov 06, 2017.
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  1. Joseph KS, Kinniburgh B, Hutcheon JA, et al. Rationalizing definitions and procedures for optimizing clinical care and public health in fetal death and stillbirth. Obstet Gynecol 2015; 125:784.
  2. World Health Organization. International Statistical Classification of Diseases and Related Health Problems, 10th ed, World Health Organization, Geneva 2004.
  3. http://www.who.int/maternal_child_adolescent/epidemiology/stillbirth/en/ (Accessed on June 15, 2016).
  4. www.stillbirthalliance.org (Accessed on February 28, 2007).
  5. GBD 2015 Child Mortality Collaborators. Global, regional, national, and selected subnational levels of stillbirths, neonatal, infant, and under-5 mortality, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet 2016; 388:1725.
  6. Lawn JE, Blencowe H, Pattinson R, et al. Stillbirths: Where? When? Why? How to make the data count? Lancet 2011; 377:1448.
  7. MacDorman MF, Gregory EC. Fetal and Perinatal Mortality: United States, 2013. Natl Vital Stat Rep 2015; 64:1.
  8. Wingate MS, Smith RA, Petrini JR, Barfield WD. Disparities in gestational age-specific fetal mortality rates in the United States, 2009-2013. Ann Epidemiol 2017; 27:570.
  9. Willinger M, Ko CW, Reddy UM. Racial disparities in stillbirth risk across gestation in the United States. Am J Obstet Gynecol 2009; 201:469.e1.
  10. Fretts RC, Schmittdiel J, McLean FH, et al. Increased maternal age and the risk of fetal death. N Engl J Med 1995; 333:953.
  11. Cnattingius S, Forman MR, Berendes HW, Isotalo L. Delayed childbearing and risk of adverse perinatal outcome. A population-based study. JAMA 1992; 268:886.
  12. Korteweg FJ, Gordijn SJ, Timmer A, et al. The Tulip classification of perinatal mortality: introduction and multidisciplinary inter-rater agreement. BJOG 2006; 113:393.
  13. Silver RM, Varner MW, Reddy U, et al. Work-up of stillbirth: a review of the evidence. Am J Obstet Gynecol 2007; 196:433.
  14. Lawn J, Shibuya K, Stein C. No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths. Bull World Health Organ 2005; 83:409.
  15. Di Mario S, Say L, Lincetto O. Risk factors for stillbirth in developing countries: a systematic review of the literature. Sex Transm Dis 2007; 34:S11.
  16. McClure EM, Nalubamba-Phiri M, Goldenberg RL. Stillbirth in developing countries. Int J Gynaecol Obstet 2006; 94:82.
  17. Fretts RC, Boyd ME, Usher RH, Usher HA. The changing pattern of fetal death, 1961-1988. Obstet Gynecol 1992; 79:35.
  18. Aminu M, Bar-Zeev S, van den Broek N. Cause of and factors associated with stillbirth: a systematic review of classification systems. Acta Obstet Gynecol Scand 2017; 96:519.
  19. Huang DY, Usher RH, Kramer MS, et al. Determinants of unexplained antepartum fetal deaths. Obstet Gynecol 2000; 95:215.
  20. Frøen JF, Arnestad M, Frey K, et al. Risk factors for sudden intrauterine unexplained death: epidemiologic characteristics of singleton cases in Oslo, Norway, 1986-1995. Am J Obstet Gynecol 2001; 184:694.
  21. Yudkin PL, Wood L, Redman CW. Risk of unexplained stillbirth at different gestational ages. Lancet 1987; 1:1192.
  22. Stillbirth Collaborative Research Network Writing Group. Causes of death among stillbirths. JAMA 2011; 306:2459.
  23. Man J, Hutchinson JC, Heazell AE, et al. Stillbirth and intrauterine fetal death: factors affecting determination of cause of death at autopsy. Ultrasound Obstet Gynecol 2016; 48:566.
  24. Alessandri LM, Stanley FJ, Newnham J, Walters BN. The epidemiological characteristics of unexplained antepartum stillbirths. Early Hum Dev 1992; 30:147.
  25. Cnattingius S, Haglund B, Kramer MS. Differences in late fetal death rates in association with determinants of small for gestational age fetuses: population based cohort study. BMJ 1998; 316:1483.
  26. Frøen JF, Gardosi JO, Thurmann A, et al. Restricted fetal growth in sudden intrauterine unexplained death. Acta Obstet Gynecol Scand 2004; 83:801.
  27. Surkan PJ, Stephansson O, Dickman PW, Cnattingius S. Previous preterm and small-for-gestational-age births and the subsequent risk of stillbirth. N Engl J Med 2004; 350:777.
  28. Zhang J, Klebanoff MA. Small-for-gestational-age infants and risk of fetal death in subsequent pregnancies. N Engl J Med 2004; 350:754.
  29. Gilbert WM, Danielsen B. Pregnancy outcomes associated with intrauterine growth restriction. Am J Obstet Gynecol 2003; 188:1596.
  30. Gardosi J, Madurasinghe V, Williams M, et al. Maternal and fetal risk factors for stillbirth: population based study. BMJ 2013; 346:f108.
  31. Bukowski R, Hansen NI, Willinger M, et al. Fetal growth and risk of stillbirth: a population-based case-control study. PLoS Med 2014; 11:e1001633.
  32. Raymond EG, Cnattingius S, Kiely JL. Effects of maternal age, parity, and smoking on the risk of stillbirth. Br J Obstet Gynaecol 1994; 101:301.
  33. Atterwill CK, Meakin JM. Delayed treatment with nerve growth factor (NGF) reverses ECMA-induced cholinergic lesions in rat brain reaggregate cultures. Biochem Pharmacol 1990; 39:2073.
  34. Goldenberg RL, McClure EM, Saleem S, Reddy UM. Infection-related stillbirths. Lancet 2010; 375:1482.
  35. Iwasenko JM, Howard J, Arbuckle S, et al. Human cytomegalovirus infection is detected frequently in stillbirths and is associated with fetal thrombotic vasculopathy. J Infect Dis 2011; 203:1526.
  36. Williams EJ, Embleton ND, Clark JE, et al. Viral infections: contributions to late fetal death, stillbirth, and infant death. J Pediatr 2013; 163:424.
  37. Sarno M, Sacramento GA, Khouri R, et al. Zika Virus Infection and Stillbirths: A Case of Hydrops Fetalis, Hydranencephaly and Fetal Demise. PLoS Negl Trop Dis 2016; 10:e0004517.
  38. Gibbs RS. The origins of stillbirth: infectious diseases. Semin Perinatol 2002; 26:75.
  39. Blackwell S, Romero R, Chaiworapongsa T, et al. Maternal and fetal inflammatory responses in unexplained fetal death. J Matern Fetal Neonatal Med 2003; 14:151.
  40. Lahra MM, Gordon A, Jeffery HE. Chorioamnionitis and fetal response in stillbirth. Am J Obstet Gynecol 2007; 196:229.e1.
  41. Morrison I, Olsen J. Weight-specific stillbirths and associated causes of death: an analysis of 765 stillbirths. Am J Obstet Gynecol 1985; 152:975.
  42. Strom CM, Ginsberg N, Applebaum M, et al. Analyses of 95 first-trimester spontaneous abortions by chorionic villus sampling and karyotype. J Assist Reprod Genet 1992; 9:458.
  43. Angell RR, Sandison A, Bain AD. Chromosome variation in perinatal mortality: a survey of 500 cases. J Med Genet 1984; 21:39.
  44. Hsu LYF. Prenatal diagnosis of chromosomal abnormalities through amniocentesis. In: Genetic disorders and the fetus, 4th ed, Milunsky A (Ed), The Johns Hopkins University Press, Baltimore 1998. p.179.
  45. Groen H, Bouman K, Pierini A, et al. Stillbirth and neonatal mortality in pregnancies complicated by major congenital anomalies: Findings from a large European cohort. Prenat Diagn 2017; 37:1100.
  46. Korteweg FJ, Bouman K, Erwich JJ, et al. Cytogenetic analysis after evaluation of 750 fetal deaths: proposal for diagnostic workup. Obstet Gynecol 2008; 111:865.
  47. Reddy UM, Goldenberg R, Silver R, et al. Stillbirth classification--developing an international consensus for research: executive summary of a National Institute of Child Health and Human Development workshop. Obstet Gynecol 2009; 114:901.
  48. Owen J, Stedman CM, Tucker TL. Comparison of predelivery versus postdelivery Kleihauer-Betke stains in cases of fetal death. Am J Obstet Gynecol 1989; 161:663.
  49. Giacoia GP. Severe fetomaternal hemorrhage: a review. Obstet Gynecol Surv 1997; 52:372.
  50. Little SE, Zera CA, Clapp MA, et al. A Multi-State Analysis of Early-Term Delivery Trends and the Association With Term Stillbirth. Obstet Gynecol 2015; 126:1138.
  51. Starikov R, Dudley D, Reddy UM. Stillbirth in the pregnancy complicated by diabetes. Curr Diab Rep 2015; 15:11.
  52. Pineles BL, Hsu S, Park E, Samet JM. Systematic Review and Meta-Analyses of Perinatal Death and Maternal Exposure to Tobacco Smoke During Pregnancy. Am J Epidemiol 2016; 184:87.
  53. Varner MW, Silver RM, Rowland Hogue CJ, et al. Association between stillbirth and illicit drug use and smoking during pregnancy. Obstet Gynecol 2014; 123:113.
  54. Sørnes T. Umbilical cord knots. Acta Obstet Gynecol Scand 2000; 79:157.
  55. Carey JC, Rayburn WF. Nuchal cord encirclements and risk of stillbirth. Int J Gynaecol Obstet 2000; 69:173.
  56. Schäffer L, Burkhardt T, Zimmermann R, Kurmanavicius J. Nuchal cords in term and postterm deliveries--do we need to know? Obstet Gynecol 2005; 106:23.
  57. Clapp JF 3rd, Stepanchak W, Hashimoto K, et al. The natural history of antenatal nuchal cords. Am J Obstet Gynecol 2003; 189:488.
  58. Larson JD, Rayburn WF, Crosby S, Thurnau GR. Multiple nuchal cord entanglements and intrapartum complications. Am J Obstet Gynecol 1995; 173:1228.
  59. Alio AP, Nana PN, Salihu HM. Spousal violence and potentially preventable single and recurrent spontaneous fetal loss in an African setting: cross-sectional study. Lancet 2009; 373:318.
  60. Janssen PA, Holt VL, Sugg NK, et al. Intimate partner violence and adverse pregnancy outcomes: a population-based study. Am J Obstet Gynecol 2003; 188:1341.
  61. Jejeebhoy SJ. Associations between wife-beating and fetal and infant death: impressions from a survey in rural India. Stud Fam Plann 1998; 29:300.
  62. Coker AL, Sanderson M, Dong B. Partner violence during pregnancy and risk of adverse pregnancy outcomes. Paediatr Perinat Epidemiol 2004; 18:260.
  63. Ahmed S, Koenig MA, Stephenson R. Effects of domestic violence on perinatal and early-childhood mortality: evidence from north India. Am J Public Health 2006; 96:1423.
  64. Stillbirth Collaborative Research Network Writing Group. Association between stillbirth and risk factors known at pregnancy confirmation. JAMA 2011; 306:2469.
  65. Conde-Agudelo A, Bird S, Kennedy SH, et al. First- and second-trimester tests to predict stillbirth in unselected pregnant women: a systematic review and meta-analysis. BJOG 2015; 122:41.
  66. Stephansson O, Dickman PW, Johansson A, Cnattingius S. Maternal hemoglobin concentration during pregnancy and risk of stillbirth. JAMA 2000; 284:2611.
  67. Bhutta ZA, Yakoob MY, Lawn JE, et al. Stillbirths: what difference can we make and at what cost? Lancet 2011; 377:1523.
  68. Sibley LM, Sipe TA, Barry D. Traditional birth attendant training for improving health behaviours and pregnancy outcomes. Cochrane Database Syst Rev 2012; :CD005460.
  69. Adam T, Lim SS, Mehta S, et al. Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries. BMJ 2005; 331:1107.
  70. Jokhio AH, Winter HR, Cheng KK. An intervention involving traditional birth attendants and perinatal and maternal mortality in Pakistan. N Engl J Med 2005; 352:2091.
  71. Goffinet F, Combier E, Bucourt M, et al. [Epidemiology of fetal deaths in the Seine-Saint-Denis perinatal survey]. J Gynecol Obstet Biol Reprod (Paris) 1996; 25:153.
  72. Pattinson R, Kerber K, Buchmann E, et al. Stillbirths: how can health systems deliver for mothers and babies? Lancet 2011; 377:1610.
  73. Saastad E, Vangen S, Frøen JF. Suboptimal care in stillbirths - a retrospective audit study. Acta Obstet Gynecol Scand 2007; 86:444.
  74. Richardus JH, Graafmans WC, Verloove-Vanhorick SP, et al. Differences in perinatal mortality and suboptimal care between 10 European regions: results of an international audit. BJOG 2003; 110:97.
  75. Flenady V, Middleton P, Smith GC, et al. Stillbirths: the way forward in high-income countries. Lancet 2011; 377:1703.
  76. Smulian JC, Ananth CV, Vintzileos AM, et al. Fetal deaths in the United States. Influence of high-risk conditions and implications for management. Obstet Gynecol 2002; 100:1183.
  77. Liu S, Joseph KS, Kramer MS, et al. Relationship of prenatal diagnosis and pregnancy termination to overall infant mortality in Canada. JAMA 2002; 287:1561.
  78. Jaquier M, Klein A, Boltshauser E. Spontaneous pregnancy outcome after prenatal diagnosis of anencephaly. BJOG 2006; 113:951.
  79. Cragan JD, Roberts HE, Edmonds LD, et al. Surveillance for anencephaly and spina bifida and the impact of prenatal diagnosis--United States, 1985-1994. MMWR CDC Surveill Summ 1995; 44:1.
  80. Holm Tveit JV, Saastad E, Stray-Pedersen B, et al. Maternal characteristics and pregnancy outcomes in women presenting with decreased fetal movements in late pregnancy. Acta Obstet Gynecol Scand 2009; 88:1345.
  81. Linde A, Pettersson K, Rådestad I. Women's Experiences of Fetal Movements before the Confirmation of Fetal Death--Contractions Misinterpreted as Fetal Movement. Birth 2015; 42:189.
  82. Sachs BP. A 38-year-old woman with fetal loss and hysterectomy. JAMA 2005; 294:833.
  83. Flenady V, Wojcieszek AM, Middleton P, et al. Stillbirths: recall to action in high-income countries. Lancet 2016; 387:691.
  84. Confidential Enquiry into Maternal and Child Health (CEMACH). Perinatal mortality surveillance, 2004: England, Wales and Northern Ireland. CEMACH, London 2006.
  85. Cotzias CS, Paterson-Brown S, Fisk NM. Prospective risk of unexplained stillbirth in singleton pregnancies at term: population based analysis. BMJ 1999; 319:287.
  86. Hilder L, Costeloe K, Thilaganathan B. Prolonged pregnancy: evaluating gestation-specific risks of fetal and infant mortality. Br J Obstet Gynaecol 1998; 105:169.
  87. Caughey AB, Musci TJ. Complications of term pregnancies beyond 37 weeks of gestation. Obstet Gynecol 2004; 103:57.
  88. Stallmach T, Hebisch G, Meier K, et al. Rescue by birth: defective placental maturation and late fetal mortality. Obstet Gynecol 2001; 97:505.
  89. Divon MY, Haglund B, Nisell H, et al. Fetal and neonatal mortality in the postterm pregnancy: the impact of gestational age and fetal growth restriction. Am J Obstet Gynecol 1998; 178:726.
  90. Campbell MK, Ostbye T, Irgens LM. Post-term birth: risk factors and outcomes in a 10-year cohort of Norwegian births. Obstet Gynecol 1997; 89:543.
  91. Smith GC. Life-table analysis of the risk of perinatal death at term and post term in singleton pregnancies. Am J Obstet Gynecol 2001; 184:489.
  92. Hedegaard M, Lidegaard Ø, Skovlund CW, et al. Reduction in stillbirths at term after new birth induction paradigm: results of a national intervention. BMJ Open 2014; 4:e005785.
  93. Stock SJ, Ferguson E, Duffy A, et al. Outcomes of elective induction of labour compared with expectant management: population based study. BMJ 2012; 344:e2838.
  94. Nicholson JM, Kellar LC, Ahmad S, et al. US term stillbirth rates and the 39-week rule: a cause for concern? Am J Obstet Gynecol 2016; 214:621.e1.
  95. https://clinicaltrials.gov/ct2/show/NCT01990612?term=Randomized+Trial+of+Induction+versus+Expectant+Management&rank=1 (Accessed on October 31, 2017).
  96. Robson S, Chan A, Keane RJ, Luke CG. Subsequent birth outcomes after an unexplained stillbirth: preliminary population-based retrospective cohort study. Aust N Z J Obstet Gynaecol 2001; 41:29.
  97. Dugoff L, Hobbins JC, Malone FD, et al. First-trimester maternal serum PAPP-A and free-beta subunit human chorionic gonadotropin concentrations and nuchal translucency are associated with obstetric complications: a population-based screening study (the FASTER Trial). Am J Obstet Gynecol 2004; 191:1446.
  98. Wenstrom KD, Owen J, Davis RO, Brumfield CG. Prognostic significance of unexplained elevated amniotic fluid alpha-fetoprotein. Obstet Gynecol 1996; 87:213.
  99. Smith GC, Shah I, Crossley JA, et al. Pregnancy-associated plasma protein A and alpha-fetoprotein and prediction of adverse perinatal outcome. Obstet Gynecol 2006; 107:161.
  100. Black M, Shetty A, Bhattacharya S. Obstetric outcomes subsequent to intrauterine death in the first pregnancy. BJOG 2008; 115:269.
  101. Heinonen S, Kirkinen P. Pregnancy outcome after previous stillbirth resulting from causes other than maternal conditions and fetal abnormalities. Birth 2000; 27:33.
  102. Goldenberg RL, Mayberry SK, Copper RL, et al. Pregnancy outcome following a second-trimester loss. Obstet Gynecol 1993; 81:444.
  103. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/low-dose-aspirin-use-for-the-prevention-of-morbidity-and-mortality-from-preeclampsia-preventive-medication (Accessed on October 31, 2017).
  104. Spong CY. Add stillbirth to the list of outcomes to worry about in a pregnant woman with a history of preterm birth or fetal growth restriction. Obstet Gynecol 2012; 119:495.
  105. ACOG Practice Bulletin No. 102: management of stillbirth. Obstet Gynecol 2009; 113:748.
  106. Gordon A, Raynes-Greenow C, McGeechan K, et al. Stillbirth risk in a second pregnancy. Obstet Gynecol 2012; 119:509.
  107. Eller AG, Branch DW, Byrne JL. Stillbirth at term. Obstet Gynecol 2006; 108:442.
  108. Weeks JW, Asrat T, Morgan MA, et al. Antepartum surveillance for a history of stillbirth: when to begin? Am J Obstet Gynecol 1995; 172:486.
  109. Spong CY, Mercer BM, D'alton M, et al. Timing of indicated late-preterm and early-term birth. Obstet Gynecol 2011; 118:323.