Temporal Trends in Stillbirth in Greece: A Longitudinal Population-Based Study

Introduction: Stillbirths are a major public health issue and a key population health indicator. The aim of this study was to comprehensively investigate and present time trends in stillbirth in Greece. Methods: Data on all live births and stillbirths were derived from the Hellenic Statistical Authority, covering a 65-year period from 1957 to 2021 and the annual stillbirth rate (SBR) was calculated, defined as the number of stillbirths per 1,000 live births and stillbirths (total births). Trends in the SBR were assessed using joinpoint regression analysis with calculation of the annual percent change (APC) with a 95% confidence interval (95% CI) and level of statistical significance p<0.05. Results: The SBR in Greece, after an initial increasing trend (1957-1965: APC=2.6, 95% CI: 0.5 to 4.7, p=0.016), and an all-time high of 15.8 per 1,000 births in 1966, recorded a four decades period of continuous improvement (1965-2003: APC=3.0, 95% CI: -3.2 to -2.8, p<0.001) and reached a historic low in 2008 (3.3 per 1,000 births) (a decrease by 79%). However, the SBR stagnated at an elevated level during the decade 2006-2016 and showed a steeply upward trend during the most recent period 2016-2021 (APC=7.4, 95% CI: 3.0 to 12.1, p=0.001). In 2021, the SBR was 5.3 per 1,000 births, 60% up from 2008. It was estimated that the SBR improvement for the 1967-2021 period resulted in 50,914 stillbirths averted (7.9 per 1,000 births), but the recent increase in the SBR has led to 1,200 additional fetal deaths (1.0 per 1,000 births) during 2009-2021. Conclusion: After an impressive decline for almost four decades the SBR gradually deteriorated during the economic crisis and finally showed an alarming rising trend after 2015, resulting in an increasing burden of fetal deaths in Greece. Further public health interventions are needed to address preventable risk factors and ensure access to optimized antenatal monitoring.