Mapping the evidence on stillbirth prevention across the reproductive continuum: an umbrella review

Clinical Snapshot

Key Findings

• P Value: Not systematically reported

• Effect Size: Variable across interventions - clear benefit demonstrated for balanced energy-protein supplementation, community health worker visits, birth preparedness, labour induction ≥37 weeks, and skilled birth attendance

• Primary Outcome: Stillbirth and perinatal mortality reduction across reproductive continuum

• Nnt Or Sensitivity: Not calculated - umbrella review of heterogeneous interventions with varying effect sizes

• Confidence Interval: Not consistently reported across all interventions

Clinical Application

Variable - some interventions (skilled birth attendance, nutritional supplementation) highly feasible, others require healthcare system strengthening Moderate relevance - Australia has low stillbirth rates but findings support continued emphasis on quality antenatal care, appropriate labour management, and avoiding reduced antenatal visit schedules. Some interventions may be relevant for Indigenous and remote populations. Pregnant women globally, with particular relevance to low- and middle-income countries where stillbirth burden is highest

Abstract

OBJECTIVES: To collate and appraise evidence from existing systematic reviews and meta-analyses on interventions to prevent stillbirth and reduce perinatal mortality across the reproductive continuum, including preconception, antenatal, intrapartum and immediate newborn periods. DESIGN: Umbrella review synthesising evidence from systematic reviews, including meta-analyses where available. DATA SOURCES: A comprehensive search was conducted in CENTRAL (via Cochrane Register of Studies Online), PubMed, Embase and Web of Science, along with trial registries (WHO International Clinical Trials Registry Platform, ClinicalTrials.gov and ISRCTN Registry), from inception to 12 January 2026. ELIGIBILITY CRITERIA: Systematic reviews and meta-analyses synthesising randomised controlled trials or quasi-experimental studies that reported stillbirth, perinatal mortality, fetal loss or fetal death were included. Reviews focused exclusively on predefined high-risk populations were excluded. DATA EXTRACTION AND SYNTHESIS: Two reviewers independently extracted data and assessed methodological quality using A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2). Grading of Recommendations, Assessment, Development and Evaluation (GRADE) certainty ratings were extracted as reported by the original review authors. Evidence synthesis followed a structured framework adapted from Ota et al, integrating direction of effect and certainty of evidence based on pooled estimates and GRADE assessments. Publication overlap was assessed using the Corrected Covered Area index where relevant. RESULTS: A total of 116 systematic reviews were included, synthesising evidence from randomised controlled and quasi-experimental studies across preconception, antenatal, intrapartum and immediate newborn periods. Evidence from individual reviews showed clear benefit for several interventions, including balanced energy-protein supplementation, home visits by community health workers, birth preparedness interventions, labour induction at or beyond 37 weeks of gestation and skilled or community-based intrapartum care, primarily for reducing perinatal mortality. Reduced antenatal visit schedules compared with standard care were associated with a possible increase in stillbirth or perinatal mortality, indicating potential harm. Many interventions-such as group antenatal care (ANC), nutritional education, case-note provision, routine ultrasound or Doppler monitoring, antibiotic treatment for bacterial vaginosis, antiretroviral therapy in pregnancy and several pharmacological or hormonal interventions-demonstrated unknown or inconclusive effects on stillbirth or perinatal mortality, largely due to imprecision and heterogeneity. CONCLUSIONS: This umbrella review identifies a range of interventions with evidence of effectiveness across the reproductive continuum, particularly those addressing maternal nutrition, continuity of ANC and quality intrapartum and newborn care. However, substantial evidence gaps remain, especially for interventions widely implemented without strong supporting evidence. These findings highlight the need for context-specific implementation research and prioritisation of proven strategies in low- and middle-income countries, where the burden of stillbirth remains highest. PROSPERO REGISTRATION NUMBER: CRD42024531100.

References

1. 1.Pathak, B. G., Vats, P., Manna, S., Yadav, S., Bhatt, A., Mukherjee, R., Patil, R., Dayma, G., & Mazumder, S. (2026). Mapping the evidence on stillbirth prevention across the reproductive continuum: an umbrella review. BMJ Open, 16(5), e110895. https://doi.org/10.1136/bmjopen-2025-110895