Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Fetal demise and stillbirth: Incidence, etiology, and prevention

Ruth C Fretts, MD, MPH
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 showing no signs of life. The terms will be used interchangeably in this topic review; however, it should be noted that parent groups prefer the term stillbirth to the other terms.

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 counseling are discussed separately:

(See "Evaluation of stillbirth".)

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


The terminology defining fetal, neonatal, perinatal, and infant death is described in detail separately (see "Perinatal mortality", section on 'Terminology'). Terminology is complicated and confusing for several reasons, including differences in the definition of fetal death among countries, differences between the definition and the criteria for reporting fetal death, the use of birth weight versus gestational age thresholds for reporting fetal death and interpretation when these values are discordant at the threshold distinguishing a fetal death from an abortus, and the sometimes significant difference between the gestational age of fetal demise and the gestational age at delivery, which impacts how the death is reported and is particularly problematic in multiple gestations with live and demised siblings.


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Apr 2016. | This topic last updated: Apr 5, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. World Health Organization. International Statistical Classification of Diseases and Related Health Problems ICD-10, 10th, World Health Organzation, Geneva 2004. Vol 2.
  2. http://apps.who.int/gho/indicatorregistry/App_Main/view_indicator.aspx?iid=2444 (Accessed on March 31, 2015).
  3. 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.
  4. www.stillbirthalliance.org (Accessed on February 28, 2007).
  5. Setel PW, Sankoh O, Rao C, et al. Sample registration of vital events with verbal autopsy: a renewed commitment to measuring and monitoring vital statistics. Bull World Health Organ 2005; 83:611.
  6. Cousens S, Blencowe H, Stanton C, et al. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet 2011; 377:1319.
  7. Lawn JE, Blencowe H, Pattinson R, et al. Stillbirths: Where? When? Why? How to make the data count? Lancet 2011; 377:1448.
  8. Hamilton BE, Miniño AM, Martin JA, et al. Annual summary of vital statistics: 2005. Pediatrics 2007; 119:345.
  9. Getahun D, Ananth CV, Kinzler WL. Risk factors for antepartum and intrapartum stillbirth: a population-based study. Am J Obstet Gynecol 2007; 196:499.
  10. CDC, National Center for Health Statistics (NCHS), National Vital Statistics Report (NversusR) 54(16) May 3, 2006. http://www.cdc.gov/nchs/data/nversusr/nversusr54/nversusr54_16.pdf (Accessed on February 28, 2007).
  11. MacDorman MF, Kirmeyer S. Fetal and perinatal mortality, United States, 2005. Natl Vital Stat Rep 2009; 57:1.
  12. MacDorman MF, Munson ML, Kirmeyer S. Fetal and perinatal mortality, United States, 2004. Natl Vital Stat Rep 2007; 56(3) www.cdc.gov/nchs/products/pubs/pubd/nvsr/nvsr.htm#vol56 (Accessed on December 17, 2007).
  13. 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.
  14. Stillbirth Collaborative Research Network Writing Group. Association between stillbirth and risk factors known at pregnancy confirmation. JAMA 2011; 306:2469.
  15. Copper RL, Goldenberg RL, DuBard MB, Davis RO. Risk factors for fetal death in white, black, and Hispanic women. Collaborative Group on Preterm Birth Prevention. Obstet Gynecol 1994; 84:490.
  16. Sharma PP, Salihu HM, Oyelese Y, et al. Is race a determinant of stillbirth recurrence? Obstet Gynecol 2006; 107:391.
  17. Salihu HM, Kinniburgh BA, Aliyu MH, et al. Racial disparity in stillbirth among singleton, twin, and triplet gestations in the United States. Obstet Gynecol 2004; 104:734.
  18. Healy AJ, Malone FD, Sullivan LM, et al. Early access to prenatal care: implications for racial disparity in perinatal mortality. Obstet Gynecol 2006; 107:625.
  19. Vintzileos AM, Ananth CV, Smulian JC, et al. Prenatal care and black-white fetal death disparity in the United States: heterogeneity by high-risk conditions. Obstet Gynecol 2002; 99:483.
  20. Kallan JE. Rates of fetal death by maternal race, ethnicity, and nativity: New Jersey, 1991-1998. JAMA 2001; 285:2978.
  21. Balchin I, Whittaker JC, Patel RR, et al. Racial variation in the association between gestational age and perinatal mortality: prospective study. BMJ 2007; 334:833.
  22. McClure EM, Wright LL, Goldenberg RL, et al. The global network: a prospective study of stillbirths in developing countries. Am J Obstet Gynecol 2007; 197:247.e1.
  23. Wigglesworth JS. Monitoring perinatal mortality. A pathophysiological approach. Lancet 1980; 2:684.
  24. Korteweg FJ, Gordijn SJ, Timmer A, et al. The Tulip classification of perinatal mortality: introduction and multidisciplinary inter-rater agreement. BJOG 2006; 113:393.
  25. Chan A, King JF, Flenady V, et al. Classification of perinatal deaths: development of the Australian and New Zealand classifications. J Paediatr Child Health 2004; 40:340.
  26. Silver RM, Varner MW, Reddy U, et al. Work-up of stillbirth: a review of the evidence. Am J Obstet Gynecol 2007; 196:433.
  27. 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.
  28. Gardosi J, Kady SM, McGeown P, et al. Classification of stillbirth by relevant condition at death (ReCoDe): population based cohort study. BMJ 2005; 331:1113.
  29. Wigglesworth JS. Classification of perinatal deaths. Soz Praventivmed 1994; 39:11.
  30. de Galan-Roosen AE, Kuijpers JC, Oei YB, et al. [Discrepancy between results of registration of perinatal cause of death by the CBS (Central Bureau of Statistics) and by personal studies in the Delft-Westland-Oostland region]. Ned Tijdschr Geneeskd 1997; 141:237.
  31. Vergani P, Cozzolino S, Pozzi E, et al. Identifying the causes of stillbirth: a comparison of four classification systems. Am J Obstet Gynecol 2008; 199:319.e1.
  32. Varli IH, Petersson K, Bottinga R, et al. The Stockholm classification of stillbirth. Acta Obstet Gynecol Scand 2008; 87:1202.
  33. 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.
  34. 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.
  35. McClure EM, Nalubamba-Phiri M, Goldenberg RL. Stillbirth in developing countries. Int J Gynaecol Obstet 2006; 94:82.
  36. Stillbirth Collaborative Research Network Writing Group. Causes of death among stillbirths. JAMA 2011; 306:2459.
  37. Fretts RC, Boyd ME, Usher RH, Usher HA. The changing pattern of fetal death, 1961-1988. Obstet Gynecol 1992; 79:35.
  38. Huang DY, Usher RH, Kramer MS, et al. Determinants of unexplained antepartum fetal deaths. Obstet Gynecol 2000; 95:215.
  39. 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.
  40. Yudkin PL, Wood L, Redman CW. Risk of unexplained stillbirth at different gestational ages. Lancet 1987; 1:1192.
  41. Alessandri LM, Stanley FJ, Newnham J, Walters BN. The epidemiological characteristics of unexplained antepartum stillbirths. Early Hum Dev 1992; 30:147.
  42. 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.
  43. Frøen JF, Gardosi JO, Thurmann A, et al. Restricted fetal growth in sudden intrauterine unexplained death. Acta Obstet Gynecol Scand 2004; 83:801.
  44. 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.
  45. Zhang J, Klebanoff MA. Small-for-gestational-age infants and risk of fetal death in subsequent pregnancies. N Engl J Med 2004; 350:754.
  46. Gilbert WM, Danielsen B. Pregnancy outcomes associated with intrauterine growth restriction. Am J Obstet Gynecol 2003; 188:1596.
  47. Gardosi J, Madurasinghe V, Williams M, et al. Maternal and fetal risk factors for stillbirth: population based study. BMJ 2013; 346:f108.
  48. 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.
  49. 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.
  50. 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.
  51. Goldenberg RL, McClure EM, Saleem S, Reddy UM. Infection-related stillbirths. Lancet 2010; 375:1482.
  52. Stormdal Bring H, Hulthén Varli IA, Kublickas M, et al. Causes of stillbirth at different gestational ages in singleton pregnancies. Acta Obstet Gynecol Scand 2014; 93:86.
  53. 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.
  54. Williams EJ, Embleton ND, Clark JE, et al. Viral infections: contributions to late fetal death, stillbirth, and infant death. J Pediatr 2013; 163:424.
  55. 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.
  56. Gibbs RS. The origins of stillbirth: infectious diseases. Semin Perinatol 2002; 26:75.
  57. Blackwell S, Romero R, Chaiworapongsa T, et al. Unexplained fetal death is associated with changes in the adaptive limb of the maternal immune response consistent with prior antigenic exposure. J Matern Fetal Neonatal Med 2003; 14:241.
  58. 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.
  59. Lahra MM, Gordon A, Jeffery HE. Chorioamnionitis and fetal response in stillbirth. Am J Obstet Gynecol 2007; 196:229.e1.
  60. Morrison I, Olsen J. Weight-specific stillbirths and associated causes of death: an analysis of 765 stillbirths. Am J Obstet Gynecol 1985; 152:975.
  61. 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.
  62. Angell RR, Sandison A, Bain AD. Chromosome variation in perinatal mortality: a survey of 500 cases. J Med Genet 1984; 21:39.
  63. 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.
  64. 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.
  65. Reddy UM, Page GP, Saade GR, et al. Karyotype versus microarray testing for genetic abnormalities after stillbirth. N Engl J Med 2012; 367:2185.
  66. 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.
  67. Giacoia GP. Severe fetomaternal hemorrhage: a review. Obstet Gynecol Surv 1997; 52:372.
  68. Sørnes T. Umbilical cord knots. Acta Obstet Gynecol Scand 2000; 79:157.
  69. Carey JC, Rayburn WF. Nuchal cord encirclements and risk of stillbirth. Int J Gynaecol Obstet 2000; 69:173.
  70. 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.
  71. Clapp JF 3rd, Stepanchak W, Hashimoto K, et al. The natural history of antenatal nuchal cords. Am J Obstet Gynecol 2003; 189:488.
  72. Larson JD, Rayburn WF, Crosby S, Thurnau GR. Multiple nuchal cord entanglements and intrapartum complications. Am J Obstet Gynecol 1995; 173:1228.
  73. Akolekar R, Bower S, Flack N, et al. Prediction of miscarriage and stillbirth at 11-13 weeks and the contribution of chorionic villus sampling. Prenat Diagn 2011; 31:38.
  74. Dugoff L, Cuckle HS, Hobbins JC, et al. Prediction of patient-specific risk for fetal loss using maternal characteristics and first- and second-trimester maternal serum Down syndrome markers. Am J Obstet Gynecol 2008; 199:290.e1.
  75. Stephansson O, Dickman PW, Johansson A, Cnattingius S. Maternal hemoglobin concentration during pregnancy and risk of stillbirth. JAMA 2000; 284:2611.
  76. 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; 377:1331.
  77. Salihu HM, Sharma PP, Aliyu MH, et al. Is small for gestational age a marker of future fetal survival in utero? Obstet Gynecol 2006; 107:851.
  78. Reddy UM, Laughon SK, Sun L, et al. Prepregnancy risk factors for antepartum stillbirth in the United States. Obstet Gynecol 2010; 116:1119.
  79. 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.
  80. 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.
  81. Jejeebhoy SJ. Associations between wife-beating and fetal and infant death: impressions from a survey in rural India. Stud Fam Plann 1998; 29:300.
  82. Coker AL, Sanderson M, Dong B. Partner violence during pregnancy and risk of adverse pregnancy outcomes. Paediatr Perinat Epidemiol 2004; 18:260.
  83. 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.
  84. Fretts RC, Schmittdiel J, McLean FH, et al. Increased maternal age and the risk of fetal death. N Engl J Med 1995; 333:953.
  85. Cnattingius S, Forman MR, Berendes HW, Isotalo L. Delayed childbearing and risk of adverse perinatal outcome. A population-based study. JAMA 1992; 268:886.
  86. Fretts RC, Usher RH. Causes of fetal death in women of advanced maternal age. Obstet Gynecol 1997; 89:40.
  87. Stephansson O, Dickman PW, Johansson A, Cnattingius S. Maternal weight, pregnancy weight gain, and the risk of antepartum stillbirth. Am J Obstet Gynecol 2001; 184:463.
  88. Stacey T, Thompson JM, Mitchell EA, et al. Association between maternal sleep practices and risk of late stillbirth: a case-control study. BMJ 2011; 342:d3403.
  89. Warland J, O'Brien LM, Heazell AE, et al. An international internet survey of the experiences of 1,714 mothers with a late stillbirth: the STARS cohort study. BMC Pregnancy Childbirth 2015; 15:172.
  90. Bell R, Glinianaia SV, Rankin J, et al. Changing patterns of perinatal death, 1982-2000: a retrospective cohort study. Arch Dis Child Fetal Neonatal Ed 2004; 89:F531.
  91. 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.
  92. Fretts RC. Etiology and prevention of stillbirth. Am J Obstet Gynecol 2005; 193:1923.
  93. Reddy UM. Prediction and prevention of recurrent stillbirth. Obstet Gynecol 2007; 110:1151.
  94. Bhutta ZA, Yakoob MY, Lawn JE, et al. Stillbirths: what difference can we make and at what cost? Lancet 2011; 377:1523.
  95. 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.
  96. 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.
  97. 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.
  98. Pattinson R, Kerber K, Buchmann E, et al. Stillbirths: how can health systems deliver for mothers and babies? Lancet 2011; 377:1610.
  99. Saastad E, Vangen S, Frøen JF. Suboptimal care in stillbirths - a retrospective audit study. Acta Obstet Gynecol Scand 2007; 86:444.
  100. 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.
  101. Flenady V, Middleton P, Smith GC, et al. Stillbirths: the way forward in high-income countries. Lancet 2011; 377:1703.
  102. Sibley LM, Sipe TA, Barry D. Traditional birth attendant training for improving health behaviours and pregnancy outcomes. Cochrane Database Syst Rev 2012; 8:CD005460.
  103. 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.
  104. 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.
  105. Jaquier M, Klein A, Boltshauser E. Spontaneous pregnancy outcome after prenatal diagnosis of anencephaly. BJOG 2006; 113:951.
  106. www.cdc.gov/mmwR/preview/mmwrhtml/00038567.htm (Accessed on March 08, 2007).
  107. 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.
  108. 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.
  109. 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.
  110. Sachs BP. A 38-year-old woman with fetal loss and hysterectomy. JAMA 2005; 294:833.
  111. Flenady V, Wojcieszek AM, Middleton P, et al. Stillbirths: recall to action in high-income countries. Lancet 2016; 387:691.
  112. Confidential Enquiry into Maternal and Child Health. Perinatal Mortality Surveillance, 2004: England, Wales and Northern Ireland. London: CEMACH, 2006.
  113. Cotzias CS, Paterson-Brown S, Fisk NM. Prospective risk of unexplained stillbirth in singleton pregnancies at term: population based analysis. BMJ 1999; 319:287.
  114. Hilder L, Costeloe K, Thilaganathan B. Prolonged pregnancy: evaluating gestation-specific risks of fetal and infant mortality. Br J Obstet Gynaecol 1998; 105:169.
  115. Caughey AB, Musci TJ. Complications of term pregnancies beyond 37 weeks of gestation. Obstet Gynecol 2004; 103:57.
  116. Stallmach T, Hebisch G, Meier K, et al. Rescue by birth: defective placental maturation and late fetal mortality. Obstet Gynecol 2001; 97:505.
  117. 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.
  118. 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.
  119. 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.
  120. Sue-A-Quan AK, Hannah ME, Cohen MM, et al. Effect of labour induction on rates of stillbirth and cesarean section in post-term pregnancies. CMAJ 1999; 160:1145.
  121. Nicholson JM, Caughey AB, Stenson MH, et al. The active management of risk in multiparous pregnancy at term: association between a higher preventive labor induction rate and improved birth outcomes. Am J Obstet Gynecol 2009; 200:250.e1.
  122. Nicholson JM, Stenson MH, Kellar LC, et al. Active management of risk in nulliparous pregnancy at term: association between a higher preventive labor induction rate and improved birth outcomes. Am J Obstet Gynecol 2009; 200:254.e1.
  123. 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.
  124. 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.
  125. ACOG Practice Bulletin No. 102: management of stillbirth. Obstet Gynecol 2009; 113:748.
  126. Eller AG, Branch DW, Byrne JL. Stillbirth at term. Obstet Gynecol 2006; 108:442.
  127. 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.
  128. Spong CY, Mercer BM, D'alton M, et al. Timing of indicated late-preterm and early-term birth. Obstet Gynecol 2011; 118:323.