National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis

Current approaches and developments in transcript profiling of the human placenta

BACKGROUND

The placenta is the active interface between mother and foetus, bearing the molecular marks of rapid development and exposures in utero. The placenta is routinely discarded at delivery, providing a valuable resource to explore maternal-offspring health and disease in pregnancy. Genome-wide profiling of the human placental transcriptome provides an unbiased approach to study normal maternal–placental–foetal physiology and pathologies.

OBJECTIVE AND RATIONALE

To date, many studies have examined the human placental transcriptome, but often within a narrow focus. This review aims to provide a comprehensive overview of human placental transcriptome studies, encompassing those from the cellular to tissue levels and contextualize current findings from a broader perspective. We have consolidated studies into overarching themes, summarized key research findings and addressed important considerations in study design, as a means to promote wider data sharing and support larger meta-analysis of already available data and greater collaboration between researchers in order to fully capitalize on the potential of transcript profiling in future studies.

SEARCH METHODS

The PubMed database, National Center for Biotechnology Information and European Bioinformatics Institute dataset repositories were searched, to identify all relevant human studies using ‘placenta’, ‘decidua’, ‘trophoblast’, ‘transcriptome’, ‘microarray’ and ‘RNA sequencing’ as search terms until May 2019. Additional studies were found from bibliographies of identified studies.

OUTCOMES

The 179 identified studies were classifiable into four broad themes: healthy placental development, pregnancy complications, exposures during pregnancy and in vitro placental cultures. The median sample size was 13 (interquartile range 8–29). Transcriptome studies prior to 2015 were predominantly performed using microarrays, while RNA sequencing became the preferred choice in more recent studies. Development of fluidics technology, combined with RNA sequencing, has enabled transcript profiles to be generated of single cells throughout pregnancy, in contrast to previous studies relying on isolated cells. There are several key study aspects, such as sample selection criteria, sample processing and data analysis methods that may represent pitfalls and limitations, which need to be carefully considered as they influence interpretation of findings and conclusions. Furthermore, several areas of growing importance, such as maternal mental health and maternal obesity are understudied and the profiling of placentas from these conditions should be prioritized.

WIDER IMPLICATIONS

Integrative analysis of placental transcriptomics with other ‘omics’ (methylome, proteome and metabolome) and linkage with future outcomes from longitudinal studies is crucial in enhancing knowledge of healthy placental development and function, and in enabling the underlying causal mechanisms of pregnancy complications to be identified. Such understanding could help in predicting risk of future adversity and in designing interventions that can improve the health outcomes of both mothers and their offspring. Wider collaboration and sharing of placental transcriptome data, overcoming the challenges in obtaining sufficient numbers of quality samples with well-defined clinical characteristics, and dedication of resources to understudied areas of pregnancy will undoubtedly help drive the field forward.

Open fire exposure increases the risk of pregnancy loss in South Asia

Interactions between climate change and anthropogenic activities result in increasing numbers of open fires, which have been shown to harm maternal health. However, few studies have examined the association between open fire and pregnancy loss. We conduct a self-comparison case-control study including 24,876 mothers from South Asia, the region with the heaviest pregnancy-loss burden in the world. Exposure is assessed using a chemical transport model as the concentrations of fire-sourced PM_2.5 (i.e., fire PM_2.5). The adjusted odds ratio (OR) of pregnancy loss for a 1-μg/m³ increment in averaged concentration of fire PM_2.5 during pregnancy is estimated as 1.051 (95% confidence intervals [CI]: 1.035, 1.067). Because fire PM_2.5 is more strongly linked with pregnancy loss than non-fire PM_2.5 (OR: 1.014; 95% CI: 1.011, 1.016), it contributes to a non-neglectable fraction (13%) of PM_2.5-associated pregnancy loss. Here, we show maternal health is threaten by gestational exposure to fire smoke in South Asia.

Adverse birth outcomes and associated factors among mothers who delivered in Bale zone hospitals, Oromia Region, Southeast Ethiopia

Objective

Adverse birth outcomes, which include stillbirth, preterm birth, low birthweight, congenital abnormalities, and stillbirth, are the leading cause of neonatal and infant mortality worldwide. We assessed adverse birth outcomes and associated factors among mothers who gave birth in Bale zone hospitals, Oromia, Southeast Ethiopia.

Methods

We used systematic random sampling in this cross-sectional study. We identified factors associated with adverse birth outcomes using bivariate analysis and multivariable logistic regression analysis.

Results

The proportion of adverse birth outcomes among participants was 21%. Of 576 births, 70 (12.2%) were low birthweight, 49 (8.5%) were preterm birth, 45 (7.8%) were stillbirth, and 18 (3.1%) infants had congenital anomalies. Inadequate antenatal care (adjusted odds ratio [AOR] = 6.58, 95% confidence interval [CI] 3.25–13.32), multiple pregnancy (AOR  =  4.74, 95% CI 1.55–14.45), premature rupture of membranes in the current pregnancy (AOR = 2.31, 95% CI 1.26–4.21), hemoglobin level  < 11 g/dL (AOR = 3.22, 95% CI 1.85–5.58), and mid-upper arm circumference less than 23 cm (AOR = 5.93, 95% CI 3.49–10.08) were all significantly associated with adverse birth outcomes.

Conclusions

Approximately one in five study participants had adverse birth outcomes. Increasing antenatal care uptake, ferrous supplementation during pregnancy, and improving the quality of maternal health services are recommended.

Predictors of stillbirth among women who had given birth in Southern Ethiopia, 2020: A case-control study

Background

Although the rate of stillbirth has decreased globally, it remains unacceptably high in low- and middle-income countries. Only ten countries including Ethiopia attribute more than 65% of global burden of still birth. Ethiopia has the 7^th highest still birth rate in the world. Identifying the predictors of stillbirth is critical for developing successful interventions and monitoring public health programs. Although certain studies have assessed the predictors of stillbirth, they failed in identify the proximate predictors of stillbirth. In addition, the inconsistent findings in identify the predictors of stillbirth, and the methodological limitations in previously published works are some of the gaps. Therefore, this study aimed to identify the predictors of stillbirth among mothers who gave birth in six referral hospitals in Southern, Ethiopia.

Methods

A hospital-based unmatched case-control study was conducted in six referral hospitals in Southern, Ethiopia from October 2019 to June 2020. Consecutive sampling techniques and simple random techniques were used to recruit cases and controls respectively. A structured standard tool was used to identify the predictors of stillbirth. Data were entered into Epi Info 7 and exported to SPSS 23 for analysis. A multivariable logistic regression model was used to identify the independent predictors of stillbirth. The goodness of fit was tested using the Hosmer and Lemeshow goodness-of-fit. In this study P-value < 0.05 was considered to declare a result as a statistically significant association.

Results

In this study 138 stillbirth cases and 269 controls were included. Women with multiple pregnancy [AOR = 2.98, 95%CI: 1.39–6.36], having preterm birth [AOR = 2.83, 95%CI: 1.58–508], having cesarean mode of delivery [AOR = 3.19, 95%CI: 1.87–5.44], having no ANC visit [AOR = 4.17, 95%CI: 2.38–7.33], and being hypertensive during pregnancy [AOR = 3.43, 95%CI: 1.93–6.06] were significantly associated with stillbirth.

Conclusions

The predictors of stillbirth identified are manageable and can be amenable to interventions. Therefore, strengthening maternal antenatal care utilization should be encouraged by providing appropriate information to the mothers. There is a need to identify, screen, and critically follow high-risk mothers: those who have different complications during pregnancy, and those undergoing cesarean section due to different indications.

Determinants of stillbirth in hospitals of North Shoa Zone, Oromia region, Central Ethiopia: A case control study

BACKGROUND

World Health Organization defined stillbirth as birth of fetus at 28 weeks or above gestation with a birth weight of ≥1000 g or body length of ≥35 cm. Majority of stillbirths occur in low and middle income nations. Efforts made in Ethiopia to improve maternal and child health are showing encouraging results, even though the magnitude didn't reach the expected level. Identification of determinants of stillbirth is quite substantial to apply further meaningful actions.

OBJECTIVE

To assess the determinants of stillbirth in hospitals of North Shoa Zone, Oromia region, Central Ethiopia.

METHOD

Institution based unmatched Case control study was conducted from March 01 to May 30/2019 among 342 women who gave birth in Fitche, Kuyu, Gundomeskel, and Muketurihospitals. Sample size was calculated by using Epi-info version 7.1.1 software package. Statistical Package for Social Sciences version 25 was used to analyze the data. Descriptive statistics, bivariate and multivariate logistic regression analysis were conducted. Variables having P-value ≤ 0.05 in multivariable logistic regression were considered as statistically significant.

RESULT

Type of labor (AOR = 3.79, 95%CI = 1.53, 9.38), duration of labor (AOR = 3.59, 95% CI = 1.53, 8.33), mal-presentation (AOR = 3.45, 95%CI = 1.99, 9.8), preeclampsia/eclampsia (AOR = 4.58, 95%CI = 1.45, 14.48) and birth defect (AOR = 3.05, 95%CI = 1.31, 7.1) were found to be the determinants of stillbirth.

CONCLUSION AND RECOMMENDATION

Causes of still birth in more than two third of the cases were identified. Type of labor, duration of labor, mal presentation, preeclampsia/eclampsia were identified as determinants of stillbirth from mothers' side while birth defect was found to be determinant of stillbirth from fetal side. Heath care providers, policy makers, and other stakeholders, should focus on identified factors to combat problems associated with still birth.

Comparison of stillbirth trends over two decades in Wales, United Kingdom and Western Australia: An international retrospective cohort study

BACKGROUND

Stillbirth is a critical public health issue worldwide. While the rates in high-income countries are relatively low, there are persistent between-country disparities.

OBJECTIVES

To compare stillbirth rates and trends in Wales and the State of Western Australia (WA), Australia, and provide insights into any differences.

METHODS

In this international retrospective cohort study, we pooled population-based data collections of all births ≥24 weeks' gestation (excluding terminations for congenital anomalies) between 1993 and 2015, divided into six time periods. The stillbirth rate per 1000 births was estimated for each cohort in each time period. Multivariable Poisson regression analyses, adjusted for appropriateness of growth, socio-economic status, maternal age, and multiple birth, were performed to evaluate the interaction between cohort and time period. Relative risk (RR) and 95% confidence interval (CI) for each time period and cohort were calculated.

RESULTS

There were 767 731 births (3725 stillbirths) in Wales and 648 373 (2431 stillbirths) in WA. The overall stillbirth rate declined by 15.9% over the study period in Wales (from 5.3 in 1993-96 to 4.5 per 1000 births in 2013-15; P_trend  < .01) but by 40.4% in WA (from 4.9 to 2.9 per 1000 births in WA; P_trend  < .01). Using 1993-96 in WA as the reference group, the adjusted RRs for stillbirths at 37-38 weeks' gestation in the most recent study period (2013-15) were 0.85 (95% CI 0.64, 1.13) in Wales and 0.51 (95% CI 0.36, 0.73) in WA.

CONCLUSIONS

The stillbirth rates between Wales and WA have widened in the last two decades (especially among late-term births), although the absolute rates for both are distinctly higher than the best-performing nations. While the differences may be partly explained by timing of birth and maternal life style behaviours such as smoking, it is important to identify and ameliorate the associated risk factors to support a reduction in preventable stillbirths.

Comparison of adverse birth outcomes among HIV-infected and HIV-uninfected women delivering in high and low risk settings in the era of universal ART in Malawi: a registry study

Background: Recent studies show that ART is associated with an adverse birth outcome in HIV-infected women.Aim: To compare rates of low birthweight (LBW) and preterm birth (PTB) between HIV-infected women receiving lifelong ART and HIV-uninfected women giving birth in low- and high-risk settings in Malawi.Methods: This observational, registry study was conducted from January 2016 to August 2017 in one large, tertiary referral hospital and four primary healthcare (PHC) facilities in Blantyre, Malawi. Women who delivered singleton live births or stillbirths of ≥20 weeks gestation were included in the analysis. Descriptive and stratified analyses were conducted using χ² tests and multivariable logistic models to control for maternal age, gravidity and health facility.Results: A total of 14,233 births were included in the analysis (7715 from the tertiary hospital and 6518 from PHC facilities). In the univariable analysis, there were no differences in rates of LBW (6.7% vs 6.4%) and PTB (42.5% vs 42.0%) between HIV-infected and -uninfected women delivering in PHC facilities. However, differences in LBW were significantly higher in HIV-infected women in multivariable analysis (LBW aOR 1.40, 95% CI 1.01-1.95). Rates of LBW and PTB were significantly higher in HIV-infected women than in uninfected women delivering at the tertiary hospital (LBW 17.6% vs 13.2%, aOR 1.53, 95% CI 1.27-1.85; PTB 28.2% vs 24.9%, aOR 1.37, 95% CI 1.17-1.60)Conclusion: Rates of adverse birth outcomes are significantly higher in HIV-infected women than in HIV-uninfected women, and this is more apparent in high-risk hospital settings than in low-risk PHC settings.

Bi-allelic loss of function variants in SLC30A5 as cause of perinatal lethal cardiomyopathy

Perinatal mortality is a heavy burden for both affected parents and physicians. However, the underlying genetic causes have not been sufficiently investigated and most cases remain without diagnosis. This impedes appropriate counseling or therapy. We describe four affected children of two unrelated families with cardiomyopathy, hydrops fetalis, or cystic hygroma that all deceased perinatally. In the four patients, we found the following homozygous loss of function (LoF) variants in SLC30A5 NM_022902.4:c.832_836del p.(Ile278Phefs*33) and NM_022902.4:c.1981_1982del p.(His661Tyrfs*10). Knockout of SLC30A5 has previously been shown a cardiac phenotype in mouse models and no homozygous LoF variants in SLC30A5 are currently described in gnomAD. Taken together, we present SLC30A5 as a new gene for a severe and perinatally lethal form of cardiomyopathy.

Prevalence assessment of sexually transmitted infections among pregnant women visiting an antenatal care center of Nepal: Pilot of the World Health Organization's standard protocol for conducting STI prevalence surveys among pregnant women

Introduction

Sexually transmitted infections (STIs) are common during pregnancy and can result in adverse delivery and birth outcomes. The purpose of this study was to estimate the prevalence of STIs; Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG), Treponema pallidum (syphilis), Trichomonas vaginalis (trichomoniasis), and Human Immunodeficiency Virus (HIV) among pregnant women visiting an antenatal care center in Nepal.

Materials and methods

We adapted and piloted the WHO standard protocol for conducting a prevalence survey of STIs among pregnant women visiting antenatal care center of Dhulikhel Hospital, Nepal. Patient recruitment, data collection, and specimen testing took place between November 2019-March 2020. First catch urine sample was collected from each eligible woman. GeneXpert platform was used for CT and NG testing. Wet-mount microscopy of urine sample was used for detection of trichomoniasis. Serological test for HIV was done by rapid and enzyme-linked immunosorbent assay tests. Serological test for syphilis was done using “nonspecific non-treponemal” and “specific treponemal” antibody tests. Tests for CT, NG and trichomoniasis were done as part of the prevalence study while tests for syphilis and HIV were done as part of the routine antenatal testing.

Results

672 women were approached to participate in the study, out of which 591 (87.9%) met the eligibility criteria and consented to participate. The overall prevalence of any STIs was 8.6% (51/591, 95% CI: 6.3–10.8); 1.5% (95% CI: 0.5–2.5) for CT and 7.1% (95% CI: 5.0–9.2) for trichomoniasis infection. None of the samples tested positive for NG, HIV or syphilis. Prevalence of any STI was not significantly different among women, age ≤ 24 years (10%, 25/229) compared to women age ≥25 years (7.1%, 26/362) (p = 0.08).

Conclusions

The prevalence of trichomoniasis among pregnant women in this sub-urban population of Nepal was high compared to few cases of CT and no cases of NG, syphilis, and HIV. The WHO standard protocol provided a valuable framework for conducting STI surveillance that can be adapted for other countries and populations.

[Intrahepatic cholestasis of pregnancy]

Intrahepatic cholestasis of pregnancy (ICP) is the most frequent pregnancy-specific liver disease. It is characterized by pruritus and an accompanying elevation of serum bile acid concentrations and/or alanine aminotransferase (ALT), which are the key parameters in the diagnosis. Despite good maternal prognosis, elevated bile acid concentration in maternal blood is an influencing factor to advers fetal outcome. The ICP is associated with increased rates of preterm birth, neonatal unit admission and stillbirth. This is the result of acute fetal asphyxia as opposed to a chronic uteroplacental insufficiency. Reliable monitoring or predictive tools (e.g. cardiotocography (CTG) or ultrasound) that help to prevent advers events are yet to be explored. Medicinal treatment with ursodeoxycholic acid (UDCA) does not demonstrably reduce adverse perinatal outcomes but does improve pruritus and liver function test results. Bile acid concentrations and gestational age should be used as indications to determine delivery. There is a high risk of recurrence in subsequent pregnancies.

Fetal and infant mortality trends according to the avoidability of causes of death and maternal education

OBJECTIVE

To estimate trends of fetal (FMR) and neonatal (NMR) mortality rates due to avoidable causes and maternal education in the city of Rio de Janeiro (2000-2018).

METHODS

Ecological time series study. Mortality and Live Birth Information System Data. The List of Avoidable Causes of Death Due to Interventions of the Brazilian Health System was used for neonatal deaths and an adaptation for fetal deaths, according to maternal education indicators (low <4 and high ≥12, years of study). Joinpoint regression models were used to estimate trends in FMR, based on one thousand births, and NMR, based on one thousand live births.

RESULTS

FMR decreased from 11.0 to 9.3% and NMR from 11.3 to 7.8% (2000/2018). In 2006, FMR (10.5%) exceeded NMR (9.0%), remaining higher. From 2000 to 2018, the annual decrease of FMR was 0.8% (2000 to 2018) and of NMR, 3.8% until 2007, decreasing to 1.1% by 2011; from then on, it remained stable. Avoidable causes, especially those reducible by adequate prenatal care, showed higher rates. Both FMR and NMR for low-education women were higher than those for the high-education level, the difference being much more pronounced for FMR, and at the end of the period: low- and high-education FMR were respectively 16.4 and 4.5% (2000) and 48.5 and 3.9% (2018), and for NMR, 18.2 and 6.7% (2000) and 28.4 and 5.0% (2018).

CONCLUSION

The favorable trend of decreasing mortality was not observed for children of mothers with low education, revealing inequalities. The causes were mostly avoidable, being related to prenatal care and childbirth.

Uncontrolled hypertension among tobacco-users: women of prime childbearing age at risk in India

BACKGROUND

Uncontrolled hypertension and tobacco use are two major public health issues that have implications for reproductive outcomes. This paper examines the association between tobacco-use status and uncontrolled hypertension among prime childbearing age (20-35) women in India.

METHODS

We used the India National Family Health Survey (NFHS-4) 2015-2016 to obtain data on hypertension status and tobacco use for 356,853 women aged 20-35. We estimated multivariate logistic regressions to obtain the adjusted odds ratio for tobacco users in favor of having uncontrolled hypertension. We examined the adjusted odds at different wealth index quintiles, at different educational attainment, and at different level of nutritional status measured by body mass index.

RESULTS

We found that the odds of having uncontrolled hypertension for the tobacco user women in India was 1.1 (95% CI: 1.01-1.19) times that of tobacco non-users at prime childbearing age. The odds were higher for tobacco-users at the poorest quintile (1.27, 95% CI: 1.14-1.42) and with no education (1.22, 95% CI: 1.10-1.34). The odds were also higher for tobacco-users who were overweight (1.88, 95% CI: 1.57-2.29) or obese (2.82, 95% CI: 1.88-4.24).

CONCLUSIONS

Our findings highlight the disproportionate dual risk of uncontrolled hypertension and tobacco use among lower-income women of prime childbearing age, identifying an opportunity for coordinated tobacco control and hypertension prevention initiatives to ensure better health of reproductive-age women in India.

Effectiveness of intrapartum fetal surveillance to improve maternal and neonatal outcomes: a systematic review and network meta-analysis

BACKGROUND:

Cesarean delivery is the most common surgical procedure worldwide. Intrapartum fetal surveillance is routinely offered to improve neonatal outcomes, but the effects of different methods on the risk of emergency cesarean deliveries remains uncertain. We conducted a systematic review and network meta-analysis to evaluate the effectiveness of different types of fetal surveillance.

METHODS:

We searched MEDLINE, Embase and CENTRAL until June 1, 2020, for randomized trials evaluating any intrapartum fetal surveillance method. We performed a network meta-analysis within a frequentist framework. We assessed the quality and network inconsistency of trials. We reported primarily on intrapartum emergency cesarean deliveries and other secondary maternal and neonatal outcomes using risk ratios (RRs) and 95% confidence intervals (CIs).

RESULTS:

We included 33 trials (118 863 patients) evaluating intermittent auscultation with Pinard stethoscope/handheld Doppler (IA), cardiotocography (CTG), computerized cardiotocography (cCTG), CTG with fetal scalp lactate (CTG-lactate), CTG with fetal scalp pH analysis (CTG-FBS), CTG with fetal pulse oximetry (FPO-CTG), CTG with fetal heart electrocardiogram (CTG-STAN) and their combinations. Intermittent auscultation reduced the risk of emergency cesarean deliveries compared with other types of surveillance (IA v. CTG: RR 0.83, 95% CI 0.72–0.97; IA v. CTG-FBS: RR 0.71, 95% CI 0.63–0.80; IA v.CTG-lactate: RR 0.77, 95% CI 0.64–0.92; IA v. FPO-CTG: RR 0.75, 95% CI 0.65–0.87; IA v.FPO-CTG-FBS: RR 0.81, 95% CI 0.67–0.99; cCTG-FBS v. IA: RR 1.21, 95% CI 1.04–1.42), except STAN-CTG-FBS (RR 1.17, 95% CI 0.98–1.40). There was a similar reduction observed for emergency cesarean deliveries for fetal distress. None of the evaluated methods was associated with a reduced risk of neonatal acidemia, neonatal unit admissions, Apgar scores or perinatal death.

INTERPRETATION:

Compared with other types of fetal surveillance, intermittent auscultation seems to reduce emergency cesarean deliveries in labour without increasing adverse neonatal and maternal outcomes.

Survey of women's report for 33 maternal and newborn indicators: EN-BIRTH multi-country validation study

BACKGROUND

Population-based household surveys, notably the Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), remain the main source of maternal and newborn health data for many low- and middle-income countries. As part of the Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study, this paper focuses on testing validity of measurement of maternal and newborn indicators around the time of birth (intrapartum and postnatal) in survey-report.

METHODS

EN-BIRTH was an observational study testing the validity of measurement for selected maternal and newborn indicators in five secondary/tertiary hospitals in Bangladesh, Nepal and Tanzania, conducted from July 2017 to July 2018. We compared women's report at exit survey with the gold standard of direct observation or verification from clinical records for women with vaginal births. Population-level validity was assessed by validity ratios (survey-reported coverage: observer-assessed coverage). Individual-level accuracy was assessed by sensitivity, specificity and percent agreement. We tested indicators already in DHS/MICS as well as indicators with potential to be included in population-based surveys, notably the first validation for small and sick newborn care indicators.

RESULTS

33 maternal and newborn indicators were evaluated. Amongst nine indicators already present in DHS/MICS, validity ratios for baby dried or wiped, birthweight measured, low birthweight, and sex of baby (female) were between 0.90-1.10. Instrumental birth, skin-to-skin contact, and early initiation of breastfeeding were highly overestimated by survey-report (2.04-4.83) while umbilical cord care indicators were massively underestimated (0.14-0.22). Amongst 24 indicators not currently in DHS/MICS, two newborn contact indicators (kangaroo mother care 1.00, admission to neonatal unit 1.01) had high survey-reported coverage amongst admitted newborns and high sensitivity. The remaining indicators did not perform well and some had very high "don't know" responses.

CONCLUSIONS

Our study revealed low validity for collecting many maternal and newborn indicators through an exit survey instrument, even with short recall periods among women with vaginal births. Household surveys are already at risk of overload, and some specific clinical care indicators do not perform well and may be under-powered. Given that approximately 80% of births worldwide occur in facilities, routine registers should also be explored to track coverage of key maternal and newborn health interventions, particularly for clinical care.

Stillbirths including intrapartum timing: EN-BIRTH multi-country validation study

BACKGROUND

An estimated >2 million babies stillborn around the world each year lack visibility. Low- and middle-income countries carry 84% of the burden yet have the least data. Most births are now in facilities, hence routine register-recording presents an opportunity to improve counting of stillbirths, but research is limited, particularly regarding accuracy. This paper evaluates register-recorded measurement of hospital stillbirths, classification accuracy, and barriers and enablers to routine recording.

METHODS

The EN-BIRTH mixed-methods, observational study took place in five hospitals in Bangladesh, Nepal and Tanzania (2017-2018). Clinical observers collected time-stamped data on perinatal care and birth outcomes as gold standard. To assess accuracy of routine register-recorded stillbirth rates, we compared birth outcomes recorded in labour ward registers to observation data. We calculated absolute rate differences and individual-level validation metrics (sensitivity, specificity, percent agreement). We assessed misclassification of stillbirths with neonatal deaths. To examine stillbirth appearance (fresh/macerated) as a proxy for timing of death, we compared appearance to observed timing of intrauterine death based on heart rate at admission.

RESULTS

23,072 births were observed including 550 stillbirths. Register-recorded completeness of birth outcomes was > 90%. The observed study stillbirth rate ranged from 3.8 (95%CI = 2.0,7.0) to 50.3 (95%CI = 43.6,58.0)/1000 total births and was under-estimated in routine registers by 1.1 to 7.3 /1000 total births (register: observed ratio 0.9-0.7). Specificity of register-recorded birth outcomes was > 99% and sensitivity varied between hospitals, ranging from 77.7-86.1%. Percent agreement between observer-assessed birth outcome and register-recorded birth outcome was very high across all hospitals and all modes of birth (> 98%). Fresh or macerated stillbirth appearance was a poor proxy for timing of stillbirth. While there were similar numbers of stillbirths misclassified as neonatal deaths (17/430) and neonatal deaths misclassified as stillbirths (21/36), neonatal deaths were proportionately more likely to be misclassified as stillbirths (58.3% vs 4.0%). Enablers to more accurate register-recording of birth outcome included supervision and data use.

CONCLUSIONS

Our results show these routine registers accurately recorded stillbirths. Fresh/macerated appearance was a poor proxy for intrapartum stillbirths, hence more focus on measuring fetal heart rate is crucial to classification and importantly reduction in these preventable deaths.

A, Ruysen H, El Arifeen S, Mee P, Gladstone ME, Blencowe H, Lawn JE. Birthweight: EN-BIRTH multi-country validation study

BACKGROUND

Accurate birthweight is critical to inform clinical care at the individual level and tracking progress towards national/global targets at the population level. Low birthweight (LBW) < 2500 g affects over 20.5 million newborns annually. However, data are lacking and may be affected by heaping. This paper evaluates birthweight measurement within the Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study.

METHODS

The EN-BIRTH study took place in five hospitals in Bangladesh, Nepal and Tanzania (2017-2018). Clinical observers collected time-stamped data (gold standard) for weighing at birth. We compared accuracy for two data sources: routine hospital registers and women's report at exit interview survey. We calculated absolute differences and individual-level validation metrics. We analysed birthweight coverage and quality gaps including timing and heaping. Qualitative data explored barriers and enablers for routine register data recording.

RESULTS

Among 23,471 observed births, 98.8% were weighed. Exit interview survey-reported weighing coverage was 94.3% (90.2-97.3%), sensitivity 95.0% (91.3-97.8%). Register-reported coverage was 96.6% (93.2-98.9%), sensitivity 97.1% (94.3-99%). Routine registers were complete (> 98% for four hospitals) and legible > 99.9%. Weighing of stillbirths varied by hospital, ranging from 12.5-89.0%. Observed LBW rate was 15.6%; survey-reported rate 14.3% (8.9-20.9%), sensitivity 82.9% (75.1-89.4%), specificity 96.1% (93.5-98.5%); register-recorded rate 14.9%, sensitivity 90.8% (85.9-94.8%), specificity 98.5% (98-99.0%). In surveys, "don't know" responses for birthweight measured were 4.7%, and 2.9% for knowing the actual weight. 95.9% of observed babies were weighed within 1 h of birth, only 14.7% with a digital scale. Weight heaping indices were around two-fold lower using digital scales compared to analogue. Observed heaping was almost 5% higher for births during the night than day. Survey-report further increased observed birthweight heaping, especially for LBW babies. Enablers to register birthweight measurement in qualitative interviews included digital scale availability and adequate staffing.

CONCLUSIONS

Hospital registers captured birthweight and LBW prevalence more accurately than women's survey report. Even in large hospitals, digital scales were not always available and stillborn babies not always weighed. Birthweight data are being captured in hospitals and investment is required to further improve data quality, researching of data flow in routine systems and use of data at every level.

Predictors of skilled birth attendance among married women in Cameroon: further analysis of 2018 Cameroon Demographic and Health Survey

BACKGROUND

In Cameroon, maternal deaths remain high. The high maternal deaths in the country have been attributed to the low utilization of maternal healthcare services, including skilled birth attendance. This study examined the predictors of skilled birth services utilization among married women in Cameroon.

METHODS

Data from the 2018 Cameroon Demographic and Health Survey was analyzed on 7881 married women of reproductive age (15-49 years). Both bivariate and multivariable logistic regression analyses were carried out to determine the predictors of skilled childbirth services. The results were presented with crude odds ratio (cOR) and adjusted odds ratio (aOR) and 95% confidence interval (CI).

RESULTS

The coverage of skilled birth attendance among married women of reproductive age in Cameroon was 66.2%. After adjusting for potential confounders, media exposure (aOR = 1.46, 95% CI: 1.11-1.91), higher decision making (aOR = 1.88, 95% CI: 1.36-2.59), maternal education (aOR = 2.38, 95% CI; 1.65-3.42), place of residence (aOR = 0.50, 95% CI; 0.33-0.74), religion (aOR = 0.55, 95% CI; 0.35-0.87), economic status (aOR = 5.16, 95% CI; 2.58-10.30), wife beating attitude (aOR = 1.32, 95% CI; 1.05-1.65), parity (aOR = 0.62, 95% CI; 0.41-0.93) and skilled antenatal care (aOR = 14.46, 95% CI; 10.01-20.89) were found to be significant predictors of skilled birth attendance.

CONCLUSIONS

This study demonstrates that social, economic, regional, and cultural factors can act as barriers to skilled childbirth services utilization in Cameroon. Interventions that target women empowerment, antenatal care awareness and strengthening are needed, especially among the rural poor, to reduce barriers to care seeking. Maternal healthcare services utilization interventions and policies in Cameroon need to focus on specific equity gaps that relate to socio-economic status, maternal education, and the economic empowerment of women. Such policies and interventions should also aim at reducing geographical barriers to access to maternal healthcare services, including skilled birth attendance. Due to the presence of inequities in the use of skilled birth attendance services, programs aimed at social protection and empowerment of economically disadvantaged women are necessary for the achievement of the post-2015 targets and the Sustainable Development Goals. Globally, Cameroon is one of the countries with high maternal deaths. Low utilization of maternal healthcare services, including skilled birth attendance have been found to account for the high maternal deaths in the country. This study sought to examine the factors associated with skilled childbirth services utilization among married women in Cameroon. Using data from the 2018 Cameroon Demographic and Health Survey, we found that the coverage of skilled birth attendance among married women of reproductive age in Cameroon is high. Factors such as higher decision-making power, higher maternal education, place of residence, religion, higher economic status, wife beating attitude, parity and skilled antenatal care were found to be the significant predictors of skilled birth attendance. This study has shown that socio-economic, regional and cultural factors account for the utilization of skilled childbirth services utilization in Cameroon. Interventions aimed at enhancing the utilization of skilled childbirth services in Cameroon should target women empowerment, antenatal care awareness creation and sensitization, especially among the rural poor, to reduce barriers to care seeking. Maternal healthcare services utilization interventions and policies in Cameroon need to focus on specific equity gaps that relate to socio-economic status, maternal education, and the economic empowerment of women.

Stillbirth in Canada: anachronistic definition and registration processes impede public health surveillance and clinical care

The archaic definition and registration processes for stillbirth currently prevalent in Canada impede both clinical care and public health. The situation is fraught because of definitional problems related to the inclusion of induced abortions at ≥20 weeks’ gestation as stillbirths: widespread uptake of prenatal diagnosis and induced abortion for serious congenital anomalies has resulted in an artefactual temporal increase in stillbirth rates in Canada and placed the country in an unfavourable position in international (stillbirth) rankings. Other problems with the Canadian stillbirth definition and registration processes extend to the inclusion of fetal reductions (for multi-fetal pregnancy) as stillbirths, and the use of inconsistent viability criteria for reporting stillbirth. This paper reviews the history of stillbirth registration in Canada, provides a rationale for updating the definition of fetal death and recommends a new definition and improved processes for fetal death registration. The recommendations proposed are intended to serve as a starting point for reformulating issues related to stillbirth, with the hope that building a consensus regarding a definition and registration procedures will facilitate clinical care and public health.

Delivery after fetal death in women with earlier cesarean section. A review

The clinical management of intrauterine fetal demise (IUFD) in women with a previous cesarean delivery presents a dilemma for the obstetrician. With the current reluctance of obstetricians to perform vaginal birth after cesarean (VBAC) and the paucity of data to counsel women regarding maternal risks, management options are limited by physician's clinical experience and biases. In the setting of fetal demise, maternal safety becomes the primary concern. Medicolegal pressures may prevent physicians from attempting a trial of labor in this situation. In this review we will a focus on frequency of birth with IUFD after cesarean section (CS), we discuss the options (VBAC vs CS), different complications, methods for induction of vaginal birth as well as risk factors of vaginal birth and cesarean delivery.

Fetal heart rate development during labour

BACKGROUND

Fresh stillbirths (FSB) and very early neonatal deaths (VEND) are important global challenges with 2.6 million deaths annually. The vast majority of these deaths occur in low- and low-middle income countries. Assessment of the fetal well-being during pregnancy, labour, and birth is normally conducted by monitoring the fetal heart rate (FHR). The heart rate of newborns is reported to increase shortly after birth, but a corresponding trend in how FHR changes just before birth for normal and adverse outcomes has not been studied. In this work, we utilise FHR measurements collected from 3711 labours from a low and low-middle income country to study how the FHR changes towards the end of the labour. The FHR development is also studied in groups defined by the neonatal well-being 24 h after birth.

METHODS

A signal pre-processing method was applied to identify and remove time periods in the FHR signal where the signal is less trustworthy. We suggest an analysis framework to study the FHR development using the median FHR of all measured heart rates within a 10-min window. The FHR trend is found for labours with a normal outcome, neonates still admitted for observation and perinatal mortality, i.e. FSB and VEND. Finally, we study how the spread of the FHR changes over time during labour.

RESULTS

When studying all labours, there is a drop in median FHR from 134 beats per minute (bpm) to 119 bpm the last 150 min before birth. The change in FHR was significant ([Formula: see text]) using Wilcoxon signed-rank test. A drop in median FHR as well as an increased spread in FHR is observed for all defined outcome groups in the same interval.

CONCLUSION

A significant drop in FHR the last 150 min before birth is seen for all neonates with a normal outcome or still admitted to the NCU at 24 h after birth. The observed earlier and larger drop in the perinatal mortality group may indicate that they struggle to endure the physical strain of labour, and that an earlier intervention could potentially save lives. Due to the low amount of data in the perinatal mortality group, a larger dataset is required to validate the drop for this group.

Investigation of stillbirth causes in Suriname: application of the WHO ICD-PM tool to national-level hospital data

Background

Suriname has one of the highest stillbirth rates in Latin America and the Caribbean. To facilitate data comparison of perinatal deaths, the World Health Organization developed the International Classification of Diseases-10 Perinatal Mortality (ICD-PM).

Objective

We aimed to (1) assess characteristics and risk indicators of women with a stillbirth, (2) determine the timing and causes of stillbirths according to the ICD-PM with critical evaluation of its application and (3) propose recommendations for the reduction of stillbirths in Suriname.

Methods

A hospital-based, nation-wide, cross-sectional study was conducted in all hospitals within Suriname during one-year (2017). The medical files of stillbirths (gestation ≥28 weeks/birth weight ≥1000 grams) were reviewed and classified using ICD-PM. We used descriptive statistics and multiple logistic regression analyses.

Results

The stillbirth rate in Suriname was 14.4/1000 births (n=131 stillbirths, n=9089 total births). Medical files were available for 86% (n=113/131) of stillbirths. Women of African descent had the highest stillbirth rate and two times the odds of stillbirth (OR 2.1, 95%CI 1.4–3.1) compared to women of other ethnicities. One third (33%, n=37/113) of stillbirths occurred after hospital admission. The timing was antepartum in 85% (n=96/113), intrapartum in 11% (n=12/113) and unknown in 4% (n=5/113). Antepartum stillbirths were caused by hypoxia in 46% (n=44/96). In 41% (n=39/96) the cause was unspecified. Maternal medical and surgical conditions were present in 50% (n=57/113), mostly hypertensive disorders.

Conclusion

Stillbirth reduction strategies in Suriname call for targeting ethnic disparities, improving antenatal services, implementing perinatal death audits and improving diagnostic post-mortem investigations. ICD-PM limited the formulation of recommendations due to many stillbirths of ‘unspecified’ causes. Based on our study findings, we also recommend addressing some challenges with applying the ICD-PM.

Abbreviations

CTG: Cardiotocography; ENAP: Every Newborn Action Plan (ENAP); ICD-PM: The WHO application of ICD-10 to deaths during the perinatal period – perinatal mortality; SBR: Stillbirth rate; SGA: Small for gestational age; WHO: World Health Organization; LMIC: Low- and middle-income countries; FHR: foetal heart rate.

[Contributions by the investigation of fetal deaths for improving the definition of underlying cause of death in the city of São Paulo, Brazil]

This study aimed to analyze the time trend in stillbirth rate (SBR) and the contribution by investigation to improving the definition of underlying cause of stillbirth in the city of São Paulo, Brazil, according to the place where the death certificate was issued. An ecological approach was used to analyze the trend in SBR by weight stratum (< 2,500g and ≥ 2,500g) and total deaths in the city in 2007-2017. Prais-Winsten generalized linear regression was used. The study of cases analyzed the underlying causes of stillbirth from 2012 to 2014, before and after the investigation, time of conclusion of the investigation, and redefinition of the underlying cause of stillbirths by type of issuer. In deaths with < 2,500g, there was an upward trend in SBR of 1.5% per year and a reduction (-1.3% per year) in stillbirths ≥ 2,500g. Total deaths presented a stable trend. In 2012-2014, 90% of deaths with ≥ 2,500g were investigated. After investigation, the underlying cause of death was redefined in 15% of the deaths, and not otherwise specified stillbirth (P95) represented 25% of the causes of death. The highest proportion of changes in the underlying cause of death occurred in deaths for which the death certificate was issued by the death certification review service (17%), while in health services the proportion was 10.6%. In conclusion, the SBR in deaths with ≥ 2,500g showed a downward trend. There was a significant redefinition of underlying causes, especially in those attested by the death certification review service. However, the redefinition was insufficient to expand the proportion of causes of death that would allow a better understanding of the mortality conditions.

Nursing interventions for perinatal bereavement care in neonatal intensive care units: A scoping review

BACKGROUND

Despite technological advances and specialist training of neonatal teams, perinatal deaths still occur. Such events are traumatic experiences for the parents and increase the risk of pathological grieving. Nursing is one of the main sources of support. However, the important work of nurses in these situations is made more difficult by the lack of recognized strategies that can be implemented to assist parents and family members in the bereavement process.

AIM

Identify nursing interventions to help parents of neonates admitted to neonatal intensive care units cope with perinatal loss.

METHODS

A scoping review based on the methodological framework established by Arksey and O'Malley was used. A total of 327 relevant studies were identified through a bibliographic search in Pubmed, CINAHL Plus, APA PsycNET and Scopus between 2000 and 2019. The screening process included an initial analysis of the relevance of the abstract and, when required, an extensive review of the full paper.

RESULTS

A total of 9 papers were finally selected which responded to the research question. All nine papers are from the USA and have different methodological characteristics. A number of effective interventions were identified, including legacy creation, support groups, family-centred accompaniment and follow-up, parental involvement in pre-mortem care, intergenerational bereavement programmes, and the use of technological and spiritual resources.

CONCLUSION

In general, the scant evidence that is available about nursing interventions around perinatal bereavement care underlines the requirement to thoroughly assess the effectiveness of those that have already been designed and implemented.

IMPLICATIONS FOR NURSING PRACTICE AND POLICY

This scoping review contributes to the potential implementation of effective interventions to deal with and help parents and family members cope with perinatal bereavement, with nursing staff as the main source of support and leading interventions which have family members in the care team. This review also makes a substantial contribution to the development of a practical and evidence-based clinical guide for nursing, with recommendations that can be adapted to effective quality care criteria. It is additionally intended to encourage visibility in health policies of care and attention to perinatal grief in neonatal intensive care units.

Perinatal Grief Among Poor Rural and Urban Women in Central India

PURPOSE

Given the pressures surrounding women's reproductive role in India, and persistent high rates of perinatal death, the purpose of this study is to describe and compare poor rural and urban Indian women's experiences of perinatal grief.

PARTICIPANTS AND METHODS

Two cross-sectional studies were compared on shared quantitative variables. Poor rural (N = 217) and urban, slum-dwelling (N = 149) Central Indian women with a history of stillbirth, and/or infant death were recruited with the aid of local community health workers. Trained, local, gender, and linguistically matched research assistants conducted the structured interviews. Shared quantitative variables include demographics, Social Provision Scale, Shortened Ways of Coping-Revised, Perinatal Grief Scale, social norms and autonomy.

RESULTS

While similar with respect to SES, age, number of living sons and perinatal loss experiences, these samples of poor women differed significantly across many variables, most notably women's household position, joint family living, number of live daughters, religious coping, autonomy, and degrees of perinatal grief. While perinatal grief was significantly associated with many variables bi-variably, most lost their relative influence in our stepwise multivariable modeling within site (rural/urban), with only social norms and social support remaining significant for rural (31% of variance) and wishful thinking and social norms for urban participants (38.4% of variance). In the combined sample household position, social support and social norms remained significant and explained 53.6% of the adjusted variance.

CONCLUSION

In both samples, perinatal grief was high following perinatal loss. Both groups of women with perinatal loss have increased risk of mental health sequelae. Notably, the context affected how they experienced perinatal grief, with rural women's grief being higher and more affected by their societal pressures and isolation. Such nuances are important considerations for much-needed tailored approaches to future interventions.

Stillbirth in Lao PDR: a healthcare provider perspective

Background

Stillbirth is a major global concern. However, most research has been conducted in high-income countries. Understanding of the experience and management of stillbirth in low-middle income countries is needed.

Objective

This qualitative study explored health professionals’ experiences of providing stillbirth care in the Lao People’s Democratic Republic, a lower-middle-income country in South-East Asia.

Methods

In-depth interviews were conducted with 33 health professionals (doctors, midwives and nurses) and thematic analysis was undertaken.

Results

All participants acknowledged stillbirth as a concern, but its incidence and causes were largely undocumented and unknown. A lack of training in managing stillbirth left health professionals often ill-equipped to support mothers and provide responsive care. Social stigma surrounds stillbirth, meaning mothers found limited support or opportunities to openly express their grief.

Conclusions

Better awareness of stillbirth causes could promote more positive experiences for healthcare providers and parents and more responsive healthcare. This requires improved training for healthcare professionals and awareness raising in the wider community.

Approaches, enablers, barriers and outcomes of implementing facility-based stillbirth and neonatal death audit in LMICs: a systematic review

PURPOSE

To identify approaches, enablers, barriers and outcomes of facility stillbirth and neonatal death audit in low-income and middle-income countries (LMICs).

DATA SOURCES

We searched MEDLINE, CINAHL Complete, Academic Search Index, Science Citation Index, Complementary index and Global health electronic databases.

STUDY SELECTION

Studies were considered eligible when reporting the approaches, enablers, barriers and outcomes of facility-based stillbirth and neonatal death audit in LMICs.

DATA EXTRACTION

Two authors independently performed the data extraction using predefined templates made before data extraction.

RESULTS OF DATA SYNTHESIS

A total of 10 articles from 7 countries were included in the final analysis. Facility or external multidisciplinary teams performed death audits on a weekly or monthly basis. A total of 1018 stillbirths and neonatal deaths were audited. Of 18 audit enablers identified, nine were at the health provider level while 18 of 23 barriers to audit that were identified occurred at the facility level. The facility-level barriers cited by more than one study included: failure to implement change; inadequate training; limited time; increased workload; too many cases and poor documentation. Six studies reported that death audits resulted in structural improvements in physical structure, training, service organisation, supplies and equipment in the wards. Five studies reported that death audits improved the standard of care, with one study showing a significant improvement in measured standards. One study reported a significant reduction in newborn mortality rate of 29.4% (95% CI 0.6% to 2.4%; p=0.0015) and one study a reduction in perinatal mortality of 4.9% (52.8% in 2007 to 47.9% in 2008) before and after perinatal audit implementation.

CONCLUSION

Stillbirth and neonatal death audit improves facility structures, processes of care and health outcomes in neonatal care. There is a need to enhance enablers and address barriers identified at both health provider and facility levels to improve the audit process.

Research priorities in maternal and neonatal health in Africa: results using the Child Health and Nutrition Research Initiative method involving over 900 experts across the continent

Background: Africa will miss the maternal and neonatal health (MNH) Sustainable Development Goals (SDGs) targets if the current trajectory is followed. The African Academy of Sciences has formed an expert maternal and newborn health group to discuss actions to improve MNH SDG targets. The team, among other recommendations, chose to implement an MNH research prioritization exercise for Africa covering four grand challenge areas. Methods: The team used the Child Health and Nutrition Research Initiative (CHNRI) research prioritization method to identify research priorities in maternal and newborn health in Africa. From 609 research options, a ranking of the top 46 research questions was achieved. Research priority scores and agreement statistics were calculated, with sub-analysis possible for the regions of East Africa, West Africa and those living out of the continent.  Results: The top research priorities generally fell into (i) improving identification of high-risk mothers and newborns, or diagnosis of high-risk conditions in mothers and newborns to improve health outcomes; (ii) improving access to treatment through improving incentives to attract and retain skilled health workers in remote, rural areas, improving emergency transport, and assessing health systems' readiness; and (iii) improving uptake of proven existing interventions such as Kangaroo Mother Care. Conclusions: The research priorities emphasized building interventions that improved access to quality healthcare in the lowest possible units of the provision of MNH interventions. The lists prioritized participation of communities in delivering MNH interventions. The current burden of disease from MNCH in Africa aligns well with the list of priorities listed from this exercise but provides extra insights into current needs by African practitioners. The MNCH Africa expert group believes that the recommendations from this work should be implemented by multisectoral teams as soon as possible to provide adequate lead time for results of the succeeding programmes to be seen before 2030.

Neonatal mortality burden and trends in UNHCR refugee camps, 2006-2017: a retrospective analysis

Background

More than 100 million people were forcibly displaced over the last decade, including millions of refugees displaced across international borders. Although refugee health and well-being has gained increasing attention from researchers in recent years, few studies have examined refugee birth outcomes or newborn health on a regional or global scale. This study uses routine health information system data to examine neonatal mortality burden and trends in refugee camps between 2006 and 2017.

Methods

Refugee population and mortality data were exported from the United Nations High Commissioner for Refugees (UNHCR) Health Information System (HIS) database. Tableau was used to export the data. Stata was used for data cleaning and statistical analysis. Neonatal mortality burdens and trends in refugee camps were analyzed and compared to national and subnational neonatal mortality rates captured by household surveys.

Findings

One hundred fifty refugee camps in 21 countries were included in this study, with an average population of 1,725,433 between 2006 and 2017. A total of 663,892 live births and 3382 neonatal deaths were captured during this period. Annual country-level refugee camp neonatal mortality rates (NMR) ranged from 12 to 56 neonatal deaths per 1000 live births. In most countries and years where national population-based surveys are available, refugee camp NMR as reported in the UNHCR HIS was lower than that of the immediate host community.

Conclusion

The UNHCR HIS provides insights into the neonatal mortality burden among refugees in camp settings and issues to consider in design and use of routine health information systems to monitor neonatal health in sub-national populations. Increased visibility of neonatal deaths and stillbirths among displaced populations can drive advocacy and inform decisions needed to strengthen health systems. Efforts to count every stillbirth and neonatal death are critical, as well as improvements to reporting systems and mechanisms for data review within broader efforts to improve the quality of neonatal care practices within and outside of health facilities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10343-5.

Determinants of stillbirths among women who gave birth at Hawassa university comprehensive specialized hospital, Hawassa, Sidama, Ethiopia 2019: a case-control study

BACKGROUND

Globally over 2.6 million pregnancy ends with stillbirth annually. Despite this fact, only a few sherds of evidence were available about factors associated with stillbirth in Ethiopia. Therefore, the study aimed to spot factors related to stillbirth among women who gave birth at Hawassa University Comprehensive Specialized Hospital Hawassa, Sidama Ethiopia, 2019.

METHODS

Facility-based unmatched case-control study was conducted at Hawassa University Comprehensive Specialized Hospital. Cases were selected using simple random sampling technique and controls were recruited to the study consecutively after every case selection with case to control ratio of 1 to 3. Data were coded and entered into Epi-data version 3.1 and exported to SPSS version 24 for analysis.

RESULTS

A total of 106 cases and 318 controls were included in the study. Number of antenatal care visit [AOR = 0.38, 95% CI (0.15, 0.95)], lack of partograph utilization [AOR = 4.1 95% CI (2.04, 10.5)], prolonged labor [AOR = 6.5, 95% CI (2.9, 14.4)], obstructed labor [AOR = 3.5, 95% CI (1.5, 9.4)], and congenital defect [AOR = 9.7, 95% CI (4.08, 23.0)] were significantly associated with stillbirth.

CONCLUSION

Absence of partograph utilization, prolonged labor, obstructed labor, antepartum hemorrhage and congenital anomaly were found to have positive association with stillbirth.

Utilization of maternal health services in rural Thawang, Rolpa district of Nepal: a community-based cross-sectional study

Purpose

This study aimed to identify the proportion and factors influencing the use of maternal health services (MHS) in rural Thawang, Rolpa, Nepal.

Design/methodology/approach

This was a community-based cross-sectional study conducted among 417 mothers who had given birth in the previous two years. Bivariate and multivariate logistic regression was applied to identify associations and predictors.

Findings

The results showed that the use of maternal health services was 50.8%. Adjusting for all other factors in the final model, age group 25–30 years (AOR: 2.30; 95% CI: 1.199–4.422), spouse communication (AOR: 7.31; 95% CI: 2.574–20.791), high accessibility (AOR: 2.552, 95% CI: 1.402–4.643) and high affordability (AOR: 10.89; 95% CI: 4.66–25.445) were significant predictors.

Research limitations/implications

This is a community-based cross-sectional study, and hence cannot establish causal relationships. The research was conducted in a limited rural area mid-Western Nepal, and this may limit the generalization of results to other settings of the country.

Practical implications

This research supports to local level government and district health authority to develop and implement need based action to increase maternal health service in the local context.

Originality/value

Underutilization of maternal health services is the result of socioeconomic dynamics, poor access to health services and other physical developments. To increase utilization of maternal health services in rural areas, there is a need to tackle the root cause of health inequality such as reducing poverty, increasing female education, involving women in employment and increasing access to health as a priority development agenda by government authorities. This research supports local level government and district health authorities to develop and implement needs-based action to increase MHS in the local context.

Prevalence of abnormal umbilical arterial flow on Doppler ultrasound in low-risk and unselected pregnant women: a systematic review

Background

While Doppler ultrasound screening is beneficial for women with high-risk pregnancies, there is insufficient evidence on its benefits and harms in low- and unselected-risk pregnancies. This may be related to fewer events of abnormal Doppler flow, however the prevalence of absent or reversed end diastolic flow (AEDF or REDF) in such women is unknown. In this systematic review, we aimed to synthesise available data on the prevalence of AEDF or REDF.

Methods

We searched PubMed, Embase, CINAHL, CENTRAL and Global Index Medicus with no date, setting or language restrictions. All randomized or non-randomized studies reporting AEDF or REDF prevalence based on Doppler assessment of umbilical arterial flow > 20 weeks’ gestation were eligible. Two authors assessed eligibility and extracted data on primary (AEDF and REDF) and secondary (fetal, perinatal, and neonatal mortality, caesarean section) outcomes, with results presented descriptively.

Results

A total of 42 studies (18,282 women) were included. Thirty-six studies reported zero AEDF or REDF cases. However, 55 AEDF or REDF cases were identified from just six studies (prevalence 0.08% to 2.13%). Four of these studies were in unselected-risk women and five were conducted in high-income countries. There was limited evidence from low- and middle-income countries.

Conclusions

Evidence from largely observational studies in higher-income countries suggests that AEDF and REDF are rare among low- and unselected-risk pregnant women. There are insufficient data from lower-income countries and further research is required.

Pregnancy intention data completeness, quality and utility in population-based surveys: EN-INDEPTH study

BACKGROUND

An estimated 40% of pregnancies globally are unintended. Measurement of pregnancy intention in low- and middle-income countries relies heavily on surveys, notably Demographic and Health Surveys (DHS), yet few studies have evaluated survey questions. We examined questions for measuring pregnancy intention, which are already in the DHS, and additional questions and investigated associations with maternity care utilisation and adverse pregnancy outcomes.

METHODS

The EN-INDEPTH study surveyed 69,176 women of reproductive age in five Health and Demographic Surveillance System sites in Ghana, Guinea-Bissau, Ethiopia, Uganda and Bangladesh (2017-2018). We investigated responses to survey questions regarding pregnancy intention in two ways: (i) pregnancy-specific intention and (ii) desired-versus-actual family size. We assessed data completeness for each and level of agreement between the two questions, and with future fertility desire. We analysed associations between pregnancy intention and number and timing of antenatal care visits, place of delivery, and stillbirth, neonatal death and low birthweight.

RESULTS

Missing data were <2% in all questions. Responses to pregnancy-specific questions were more consistent with future fertility desire than desired-versus-actual family size responses. Using the pregnancy-specific questions, 7.4% of women who reported their last pregnancy as unwanted reported wanting more children in the future, compared with 45.1% of women in the corresponding desired family size category. Women reporting unintended pregnancies were less likely to attend 4+ antenatal care visits (aOR 0.73, 95% CI 0.64-0.83), have their first visit during the first trimester (aOR 0.71, 95% CI 0.63-0.79), and report stillbirths (aOR 0.57, 95% CI 0.44-0.73) or neonatal deaths (aOR 0.79, 95% CI 0.64-0.96), compared with women reporting intended pregnancies. We found no associations for desired-versus-actual family size intention.

CONCLUSIONS

We found the pregnancy-specific intention questions to be a much more reliable assessment of pregnancy intention than the desired-versus-actual family size questions, despite a reluctance to report pregnancies as unwanted rather than mistimed. The additional questions were useful and may complement current DHS questions, although these are not the only possibilities. As women with unintended pregnancies were more likely to miss timely and frequent antenatal care, implementation research is required to improve coverage and quality of care for those women.

Data-Driven Modeling of Pregnancy-Related Complications

A healthy pregnancy depends on complex interrelated biological adaptations involving placentation, maternal immune responses, and hormonal homeostasis. Recent advances in high-throughput technologies have provided access to multiomics biological data that, combined with clinical and social data, can provide a deeper understanding of normal and abnormal pregnancies. Integration of these heterogeneous datasets using state-of-the-art machine-learning methods can enable the prediction of short- and long-term health trajectories for a mother and offspring and the development of treatments to prevent or minimize complications. We review advanced machine-learning methods that could: provide deeper biological insights into a pregnancy not yet unveiled by current methodologies; clarify the etiologies and heterogeneity of pathologies that affect a pregnancy; and suggest the best approaches to address disparities in outcomes affecting vulnerable populations.

Barriers and enablers to reporting pregnancy and adverse pregnancy outcomes in population-based surveys: EN-INDEPTH study

BACKGROUND

Risks of neonatal death, stillbirth and miscarriage are highest in low- and middle-income countries (LMICs), where data has most gaps and estimates rely on household surveys, dependent on women reporting these events. Underreporting of pregnancy and adverse pregnancy outcomes (APOs) is common, but few studies have investigated barriers to reporting these in LMICs. The EN-INDEPTH multi-country study applied qualitative approaches to explore barriers and enablers to reporting pregnancy and APOs in surveys, including individual, community, cultural and interview level factors.

METHODS

The study was conducted in five Health and Demographic Surveillance System sites in Guinea-Bissau, Ethiopia, Uganda, Bangladesh and Ghana. Using an interpretative paradigm and phenomenology methodology, 28 focus group discussions were conducted with 82 EN-INDEPTH survey interviewers and supervisors and 172 women between February and August 2018. Thematic analysis was guided by an a priori codebook.

RESULTS

Survey interview processes influenced reporting of pregnancy and APOs. Women found questions about APOs intrusive and of unclear relevance. Across all sites, sociocultural and spiritual beliefs were major barriers to women reporting pregnancy, due to fear that harm would come to their baby. We identified several factors affecting reporting of APOs including reluctance to speak about sad memories and variation in recognition of the baby's value, especially for APOs at earlier gestation. Overlaps in local understanding and terminology for APOs may also contribute to misreporting, for example between miscarriages and stillbirths. Interviewers' skills and training were the keys to enabling respondents to open up, as was privacy during interviews.

CONCLUSION

Sociocultural beliefs and psycho-social impacts of APOs play a large part in underreporting these events. Interviewers' skills, careful tool development and translation are the keys to obtaining accurate information. Reporting could be improved with clearer explanations of survey purpose and benefits to respondents and enhanced interviewer training on probing, building rapport and empathy.

Birth, stillbirth and death registration data completeness, quality and utility in population-based surveys: EN-INDEPTH study

BACKGROUND

Birth registration is a child's first right. Registration of live births, stillbirths and deaths is foundational for national planning. Completeness of birth registration for live births in low- and middle-income countries is measured through population-based surveys which do not currently include completeness of stillbirth or death registration.

METHODS

The EN-INDEPTH population-based survey of women of reproductive age was undertaken in five Health and Demographic Surveillance System sites in Bangladesh, Ethiopia, Ghana, Guinea-Bissau and Uganda (2017-2018). In four African sites, we included new/modified questions regarding registration for 1177 stillbirths and 11,881 livebirths (1333 neonatal deaths and 10,548 surviving the neonatal period). Questions were evaluated for completeness of responses, data quality, time to administer and estimates of registration completeness using descriptive statistics. Timing of birth registration, factors associated with non-registration and reported barriers were assessed using descriptive statistics and logistic regression.

RESULTS

Almost all women, irrespective of their baby's survival, responded to registration questions, taking an average of < 1 min. Reported completeness of birth registration was 30.7% (6.1-53.5%) for babies surviving the neonatal period, compared to 1.7% for neonatal deaths (0.4-5.7%). Women were able to report age at birth registration for 93.6% of babies. Non-registration of babies surviving the neonatal period was significantly higher for home-born children (aOR 1.43 (95% CI 1.27-1.60)) and in Dabat (Ethiopia) (aOR 4.11 (95% CI 3.37-5.01)). Other socio-demographic factors associated with non-registration included younger age of mother, more prior births, little or no education, and lower socio-economic status. Neonatal death registration questions were feasible (100% women responded; only 1% did not know), revealing extremely low completeness with only 1.2% of neonatal deaths reported as registered. Despite > 70% of stillbirths occurring in facilities, only 2.5% were reported as registered.

CONCLUSIONS

Questions on birth, stillbirth and death registration were feasible in a household survey. Completeness of birth registration is low in all four sites, but stillbirth and neonatal death registration was very low. Closing the registration gap amongst facility births could increase registration of both livebirths and facility deaths, including stillbirths, but will require co-ordination between civil registration systems and the often over-stretched health sector. Investment and innovation is required to capture birth and especially deaths in both facility and community systems.

Four decades of measuring stillbirths and neonatal deaths in Demographic and Health Surveys: historical review

BACKGROUND

Worldwide, an estimated 5.1 million stillbirths and neonatal deaths occur annually, 98% in low- and middle-income countries. Limited coverage of civil and vital registration systems necessitates reliance on women's retrospective reporting in household surveys for data on these deaths. The predominant platform, Demographic and Health Surveys (DHS), has evolved over the last 35 years and differs by country, yet no previous study has described these differences and the effects of these changes on stillbirth and neonatal death measurement.

METHODS

We undertook a review of DHS model questionnaires, protocols and methodological reports from DHS-I to DHS-VII, focusing on the collection of information on stillbirth and neonatal deaths describing differences in approaches, questionnaires and geographic reach up to December 9, 2019. We analysed the resultant data, applied previously used data quality criteria including ratios of stillbirth rate (SBR) to neonatal mortality rate (NMR) and early NMR (ENMR) to NMR, comparing by country, over time and by DHS module.

RESULTS

DHS has conducted >320 surveys in 90 countries since 1984. Two types of maternity history have been used: full birth history (FBH) and full pregnancy history (FPH). A FBH collecting information only on live births has been included in all model questionnaires to date, with data on stillbirths collected through a reproductive calendar (DHS II-VI) or using additional questions on non-live births (DHS-VII). FPH collecting information on all pregnancies including live births, miscarriages, abortions and stillbirths has been used in 17 countries. We found no evidence of variation in stillbirth data quality assessed by SBR:NMR over time for FBH surveys with reproductive calendar, some variation for surveys with FBH in DHS-VII and most variation among the surveys conducted with a FPH. ENMR:NMR ratio increased over time, which may reflect changes in data quality or real epidemiological change.

CONCLUSION

DHS remains the major data source for pregnancy outcomes worldwide. Although the DHS model questionnaire has evolved over the last three and half decades, more robust evidence is required concerning optimal methods to obtain accurate data on stillbirths and neonatal deaths through household surveys and also to develop and test standardised data quality criteria.

Stillbirth outcome capture and classification in population-based surveys: EN-INDEPTH study

BACKGROUND

Household surveys remain important sources of stillbirth data, but omission and misclassification are common. Classifying adverse pregnancy outcomes as stillbirths requires accurate reporting of vital status at birth and gestational age or birthweight for every pregnancy. Further categorisation, e.g. by sex, or timing (intrapartum/antepartum) improves data to understand and prevent stillbirth.

METHODS

We undertook a cross-sectional population-based survey of women of reproductive age in five health and demographic surveillance system sites in Bangladesh, Ethiopia, Ghana, Guinea-Bissau and Uganda (2017-2018). All women answered a full birth history with pregnancy loss questions (FBH+) or a full pregnancy history (FPH). A sub-sample across both groups were asked additional stillbirth questions. Questions were evaluated using descriptive measures. Using an interpretative paradigm and phenomenology methodology, focus group discussions with women exploring barriers to reporting birthweight for stillbirths were conducted. Thematic analysis was guided by an a priori codebook.

RESULTS

Overall 69,176 women reported 98,483 livebirths (FBH+) and 102,873 pregnancies (FPH). Additional questions were asked for 1453 stillbirths, 1528 neonatal deaths and 12,620 surviving children born in the 5 years prior to the survey. Completeness was high (> 99%) for existing FBH+/FPH questions on signs of life at birth and gestational age (months). Discordant responses in signs of life at birth between different questions were common; nearly one-quarter classified as stillbirths on FBH+/FPH were reported born alive on additional questions. Availability of information on gestational age (weeks) (58.1%) and birthweight (13.2%) was low amongst stillbirths, and heaping was common. Most women (93.9%) were able to report the sex of their stillborn baby. Response completeness for stillbirth timing (18.3-95.1%) and estimated proportion intrapartum (15.6-90.0%) varied by question and site. Congenital malformations were reported in 3.1% stillbirths. Perceived value in weighing a stillborn baby varied and barriers to weighing at birth a nd knowing birthweight were common.

CONCLUSIONS

Improving stillbirth data in surveys will require investment in improving the measurement of vital status, gestational age and birthweight by healthcare providers, communication of these with women, and overcoming reporting barriers. Given the large burden and effect on families, improved data must be made available to end preventable stillbirths.

Late initiation of antenatal care and associated factors among pregnant women attending antenatal clinic of Ilu Ababor Zone, southwest Ethiopia: A cross-sectional study

Timely entries to antenatal care have various benefits for pregnant women and birth outcomes. The aim of antenatal care is to assure that every pregnancy culminates in the delivery of a healthy baby without negative effects on the health of pregnant women through health promotion and disease prevention, early detection, and treatment of complications and existing diseases. Hence, this study assessed the late initiation of antenatal care and associated factors among pregnant women attending antenatal clinics at public health centers of Ilu Ababor Zone, southwest Ethiopia. An Institution-based cross-sectional study was carried out among 389 pregnant women who were attending antenatal care service at twelve randomly selected health centers. A systematic sampling technique was employed to recruit pregnant women. Pretested and structured questionnaires were used to collect data. Data were entered into Epidata and exported to SPSS for analysis. Those women who started antenatal care follow up after 12 weeks of gestational age were categorized as booked lately. Bivariable and multivariable logistic regression was employed to identify an association between the independent predictors and the outcome variable. In this study, 277 (71.2%) of the participants were booked their first antenatal care visit lately. Having family size of ≥ 4 (AOR: 2.25; 95% CI: 1.07–4.74), maternal age ≥ 25 years (AOR: 2.30; 95%CI: 1.02–5.18) and perceived the right time of booking > 12 weeks of gestation (AOR: 2.39; 95% CI: 1.13–5.04) had higher odds of late antenatal care initiation. Similarly, not being a member of women’s health developmental army (AOR: 2.35; 95%CI: 1.09–5.07) and ANC not attended previously (AOR: 3.32; 95% CI: 1.17–9.42) had also a more likelihood of booking antenatal care lately. In this study, the majority of women started antenatal care lately. Thus, the provision of health education on the importance of attending first antenatal care early is recommended.

Assessing the impact of a motivational intervention to improve the working lives of maternity healthcare workers: a quantitative and qualitative evaluation of a feasibility study in Malawi

BACKGROUND

Globally too many mothers and babies die during childbirth; 98% of maternal deaths are avoidable. Skilled clinicians can reduce these deaths; however, there is a world-wide shortage of maternity healthcare workers. Malawi has enough to deliver 20% of its maternity care. A motivating work environment is important for healthcare worker retention. To inform a future trial, we aimed to assess the feasibility of implementing a motivational intervention (Appreciative Inquiry) to improve the working lives of maternity healthcare workers and patient satisfaction in Malawi.

METHODS

Three government hospitals participated over 1 year. Its effectiveness was assessed through: a monthly longitudinal survey of working life using psychometrically validated instruments (basic psychological needs, job satisfaction and work-related quality of life); a before and after questionnaire of patient satisfaction using a patient satisfaction tool validated in low-income settings with a maximum score of 80; and a qualitative template analysis encompassing ethnographic data, semi-structured interviews and focus groups with staff.

RESULTS

The intervention was attended by all 145 eligible staff, who also participated in the longitudinal study. The general trend was an increase in the scores for each scale except for the basic psychological needs score in one site. Only one site demonstrated strong evidence for the intervention working in the work-related quality of life scales. Pre-intervention, 162 postnatal women completed the questionnaire; post-intervention, 191 postnatal women participated. Patient satisfaction rose in all three sites; referral hospital 4.41 rise (95% CI 1.89 to 6.95), district hospital 10.22 (95% CI 7.38 to 13.07) and community hospital 13.02 (95% CI 10.48 to 15.57). The qualitative data revealed that staff felt happier, that their skills (especially communication) had improved, behaviour had changed and systems had developed.

CONCLUSIONS

We have shown that it is possible to implement Appreciative Inquiry in government facilities in Malawi, which has the potential to change the way staff work and improve patient satisfaction. The mixed methods approach revealed important findings including the importance of staff relationships. We have identified clear implementation elements that will be important to measure in a future trial such as implementation fidelity and inter-personal relationship factors.

Grief reaction and psychosocial impacts of child death and stillbirth on bereaved North Indian parents: A qualitative study

BACKGROUND

Grief following stillbirth and child death are one of the most traumatic experience for parents with psychosomatic, social and economic impacts. The grief profile, severity and its impacts in Indian context are not well documented. This study documented the grief and coping experiences of the Indian parents following stillbirth and child death.

METHODS

This exploratory qualitative study in Delhi (India) included in-depth interviews with parents (50 mothers and 49 fathers), who had stillbirth or child death, their family members (n = 41) and community representatives (n = 12). Eight focus group discussions were done with community members (n = 72). Inductive data analysis included thematic content analysis. Perinatal Grief Scale was used to document the mother's grief severity after 6-9 months of loss.

RESULTS

The four themes emerged were grief anticipation and expression, impact of the bereavement, coping mechanism, and sociocultural norms and practices. The parents suffered from disbelief, severe pain and helplessness. Mothers expressed severe grief openly and some fainted. Fathers also had severe grief, but didn't express openly. Some parents shared self-guilt and blamed the hospital/healthcare providers, themselves or family. Majority had no/positive change in couple relationship, but few faced marital disharmony. Majority experienced sleep, eating and psychological disturbances for several weeks. Mothers coped through engaging in household work, caring other child(ren) and spiritual activities. Fathers coped through avoiding discussion and work and professional engagement. Fathers resumed work after 5-20 days and mothers took 2-6 weeks to resume household chores. Unanticipated loss, limited family support and financial strain affected the severity and duration of grief. 57.5% of all mothers and 80% mothers with stillbirth had severe grief after 6-9 months.

CONCLUSIONS

Stillbirth and child death have lasting psychosomatic, social and economic impacts on parents, which are usually ignored. Sociocultural and religion appropriate bereavement support for the parents are needed to reduce the impacts.

Determinants of Stillbirth Among Deliveries Attended in Bale Zone Hospitals, Oromia Regional State, Southeast Ethiopia: A Case-Control Study

Background

Stillbirth is one of the adverse outcomes of pregnancy, and it is among the major public health problems in developing countries including Ethiopia. Stillbirth has wide-reaching consequences for parents, care providers, community and society at large.

Purpose

To assess the determinant of stillbirth among deliveries attended in Bale zone hospitals Southeast Ethiopia.

Methods

An institution-based unmatched case-control study was conducted. Cases were deliveries whose birth outcome was stillbirth and controls were deliveries with live birth. A pretested and structured checklist was used to collect data from a sample of 402 (134 cases and 268 controls). Systematic random sampling was used to recruit samples from a list of charts in the delivery registration book. Data were entered into EpiData version 4.2 and exported to SPSS version 20 for analysis. Crude and adjusted odds ratio with 95%CI was calculated and P-value <0.05 was used to declare statistical significance.

Results

A total of 402 charts of mothers (134 cases and 268 controls) were included in the analysis. Preceding birth interval <24 months (AOR: 2.991; 95%CI: 1.351-6.621), antenatal visit started at third trimester (AOR: 2.739; 95%CI: 1.048-7.158), referred from other health facility (AOR: 3.215; 95%CI: 1.430-7.229), labor length ≥24 h (AOR: 3.169; 95%CI: 1.241-8.091), presence of meconium stained amniotic fluid (AOR: 2.670; 95%CI: 1.082-6.592) and giving birth to a baby <2500 g (AOR: 3.155; 95%CI: 1.235-8.07) were determinants of stillbirth.

Conclusion

Preceding birth interval of <24 months, antenatal visit started at third trimester, referred from other health facility, presence of meconium stained amniotic fluid, labor length ≤24 h and giving birth to a baby <2500 g were found the determinants of stillbirth. Intrapartum care, early identification of labor complications and referral system are required.

Ethnic disparities in stillbirth risk in Yunnan, China: a prospective cohort study, 2010-2018

Background

Racial and ethnic disparities in stillbirth risk had been documented in most western countries, but it remains unknown in China. This study was to determine whether exist ethnic disparities in stillbirth risk in mainland China.

Methods

Pregnancy outcomes and ethnicity data were obtained from the National Free Preconception Health Examination Project (NEPHEP), a nationwide prospective population-based cohort study conducted in Yunnan China from 2010-2018. The Han majority and other four main minorities including Yi, Dai, Miao, Hani were investigated in the analysis. The stillbirth hazards were estimated by life-table analysis. The excess stillbirth risk (ESR) was computed for Chinese minorities using multivariable logistic regression.

Results

Compared with other four minorities, women in Han majority were more likely to more educated, less multiparous, and less occupied in agriculture. The pattern of stillbirth hazard of Dai women across different gestation intervals were found to be different from other ethnic groups, especially in 20-23 weeks with 3.2 times higher than Han women. The ESR of the Dai, Hani, Miao, and Yi were 45.05, 18.70, -4.17 and 12.28%, respectively. Adjusted for maternal age, education, birth order and other general risk factors, the ethnic disparity still persisted between Dai women and Han women. Adjusted for preterm birth further (gestation age <37 weeks) can reduce 16.91% ESR of Dai women and made the disparity insignificant. Maternal diseases and congenital anomalies explained little for ethnic disparities.

Conclusions

We identified the ethnic disparity in stillbirth risk between Dai women and Han women. General risk factors including sociodemographic factors and maternal diseases explained little. Considerable ethnic disparities can be attributed to preterm birth.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10102-y.

The trend and characteristics of stillbirth delivery in a university teaching hospital in Lagos, Nigeria

Background:

The burden of stillbirth is so huge in sub-Saharan Africa, especially in Nigeria where many mothers and mothers-to-be are denied the joy of motherhood. Despite the frequent occurrence of this obstetric problem in our environment, little priority is placed on it.

Objectives:

The study aims to bring to the fore, the burden, trend, and characteristics of stillbirth delivery in Lagos, Nigeria.

Subjects and Methods:

This was a 5-year descriptive retrospective study of the case records of women who had stillbirth delivery at Lagos University Teaching Hospital from January 2009 to December 2013. Relevant information was obtained using a study pro forma, and data analysis was carried out using SPSS version 20.0.

Results:

The prevalence of stillbirth was 6.2%, and the rate was 61.8/1000 total births. Women who did not book for antenatal care accounted for 76.2% of the cases, and the antenatal and intrapartum stillbirths accounted for 64.6% and 35.4%, respectively. The mean gestational age was 35.5 ± 1.2 weeks, while the mean birth weight was 2.9 ± 1.0 kg. Majority of the stillbirths were male fetuses (54.5%). Previous history of stillbirth (36.0%), hypertensive disorders in pregnancy (33.0%), placental abruption (28.8%), intrauterine growth restriction (13.0%), and ruptured uterus (11.3%) were the common clinical risk factors identified.

Conclusion:

The burden of stillbirth is high in our environment, and majority is due to preventable or manageable obstetric conditions. There is a need to encourage early referral of complicated pregnancies and labor to specialized centers that can cater for them, so as to avoid unnecessary and preventable deaths.

The effect of antenatal care on perinatal outcomes in Ethiopia: A systematic review and meta-analysis

BACKGROUND

The estimated annual global perinatal and neonatal death is four million. Stillbirths are almost equivalent to neonatal mortality, yet they have not received the same attention. Antenatal care is generally thought to be an effective method of improving pregnancy outcomes, but its effectiveness as a means of reducing perinatal mortality has not been evaluated in Ethiopia. Therefore, we will identify the pooled effect of antenatal care on perinatal outcomes in Ethiopia.

METHODS

Medline, Embase, Cinahl, African journal online and Google Scholar was searched for articles published in English language between January 1990 and May 2020. Two independent assessors selected studies and extracted data from eligible articles. The Risk of Bias Assessment tool for Non-Randomized Studies was used to assess the quality of each included study. Data analysis was performed using RevMan 5.3. Heterogeneity and publication bias were assessed using I2 test statistical significance and Egger's test for small-study effects respectively. The random effect model was employed, and forest plot was used to present the risk ratio (RR) with 95% confidence interval (CI).

RESULTS

Thirteen out of seventeen included studies revealed antenatal care utilization had a significant association with perinatal outcomes. The pooled risk ratio by the random-effects model for perinatal death was 0.42 (95% CI: 0.34, 0.52); stillbirth 0.34 (95% CI: 0.25, 0.46); early neonatal death 0.85 (95% CI: 0.21. 3.49).

CONCLUSION

Women who attended at least one antenatal care visit were more likely to give birth to an alive neonate that survives compared to their counterpart. Therefore, the Ethiopian Ministry of health and other stakeholders should design tailored interventions to increase antenatal care utilization since it has been shown to reduce perinatal mortality.

Potentially preventable antepartum stillbirths in a high-resource setting: a prospective audit-based study

OBJECTIVES

The primary objective was the identification of sub-standard care in antepartum stillbirths in Emilia-Romagna Region (Italy), hence the number of potentially preventable cases. Secondly, we seek to evaluate any association between inadequate care and either risk factors for stillbirth or causes of death.

STUDY DESIGN

This study was based on prospectively-collected data in an institutional stillbirth audit project, involving all 29 hospital with a maternity unit in Emilia-Romagna Region. For each stillbirth occurred in the area from 2014 to the first semester of 2019 the same diagnostic workup was performed and a clinical record with data about mother and stillborn was completed. Every case was discussed in a multidisciplinary local audit to assess both the cause of death and the quality of care. Two aspects of care quality were evaluated: clinical management and women's access to care. Data were then reviewed by the Regional Audit Group.

RESULTS

Elements of inadequate care were identified in 56 out of 524 (10.7 %) fetal deaths. Non-Italian women and pregnancies with fetal growth restriction had double the risk of having received inadequate care during pregnancy, compared to Italian women (aOR 2.0, 95 % CI 1.1-3.6) and a normally developing fetus (aOR 2.0, 95 % CI 1.1-4.1), respectively. Women whose stillbirth was caused by maternal disorders were at higher risk for inadequate care compared to women who had stillbirth explained by other cause (aOR 5.89, 95 %CI 2.2-15.4). Sub-optimal clinical management and barriers to access to care were observed to equal extents. Inappropriate ultrasound monitoring was the most frequent suboptimal care element.

CONCLUSIONS

About one out of ten stillbirths was potentially preventable. Interventions to reduce stillbirth occurrence in our high-resource setting should focus on appropriate diagnosis and management of maternal disorders and fetal growth restriction, as well as improving access to antenatal care.

An analytic perspective of a mixed methods study during humanitarian crises in South Sudan: translating facility- and community-based newborn guidelines into practice

Background

In South Sudan, the civil war in 2016 led to mass displacement in Juba that rapidly spread to other regions of the country. Access to health care was limited because of attacks against health facilities and workers and pregnant women and newborns were among the most vulnerable. Translation of newborn guidelines into public health practice, particularly during periods of on-going violence, are not well studied during humanitarian emergencies. During 2016 to 2017, we assessed the delivery of a package of community- and facility-based newborn health interventions in displaced person camps to understand implementation outcomes. This case analysis describes the challenges encountered and mitigating strategies employed during the conduct of an original research study.

Discussion

Challenges unique to conducting research in South Sudan included violent attacks against humanitarian aid workers that required research partners to modify study plans on an ongoing basis to ensure staff and patient safety. South Sudan faced devastating cholera and measles outbreaks that shifted programmatic priorities. Costs associated with traveling study staff and transporting equipment kept rising due to hyperinflation and, after the July 2016 violence, the study team was unable to convene in Juba for some months to conduct refresher trainings or monitor data collection. Strategies used to address these challenges were: collaborating with non-research partners to identify operational solutions; maintaining a locally-based study team; maintaining flexible budgets and timelines; using mobile data collection to conduct timely data entry and remote quality checks; and utilizing a cascade approach for training field staff.

Conclusions

The case analysis provides lessons that are applicable to other humanitarian settings including the need for flexible research methods, budgets and timelines; innovative training and supervision; and a local research team with careful consideration of sociopolitical factors that impact their access and safety. Engagement of national and local stakeholders can ensure health services and data collection continue and findings translate to public health action, even in contexts facing severe and unpredictable insecurity.

Prioritization of interventions in pursuit of maternal health policy objectives to mitigate stillbirth risks. An exploratory qualitative study at subnational level in Uganda

Background

Global calls for renewed efforts to address stillbirth burden highlighted areas for policy and implementation resulting in national level translations. Information regarding adapted strategies to effect policy objectives into service delivery by frontline health workers remains scanty especially at subnational level. The study explored strategies prioritized to mitigate stillbirth risk in the context of operationalizing recommendations from the global campaigns at a subnational level in Uganda.

Methods

A cross-sectional qualitative exploratory study was conducted among a purposively selected sample of sixteen key informants involved in delivery of maternal and child health services in Mukono district. Analysis followed thematic content analysis deductively focusing on those policy priorities highlighted in the global stillbirth campaigns and reflected at the national level in the different guidelines. Results.

Interventions to address stillbirth followed prioritization of service delivery aspects to respond to identified gaps. Efforts to increase uptake of family planning services for example included offering it at all entry points into care with counseling forming part of the package following stillbirth. Referrals were streamlined by focusing on addressing delays from the referring entity while antenatal care attendance was boosted through provision of incentives to encourage mothers to comply. Other prioritized aspects included perinatal death audits and improvements in data systems while differentiated care focused on aligning resources to support high risk mothers. This was in part influenced by the limited resources and skills which made health workers to adapt routine to fit implementation context.

Conclusions

The resource availability determined aspects of policy to prioritize while responding to stillbirth risk at subnational level by frontline health workers. Their understanding of risk, feasibility of implementation and the desire for optimal health systems performance worked to define the nature of services delivered calling for purposeful consideration of resource availability and implementation context while prioritizing stillbirth reduction at subnational level.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-06046-z.

Understanding the complexities of unexplained stillbirth in sub-Saharan Africa: a mixed-methods study

Objective

To understand the complexities surrounding unexplained stillbirth for the development and implementation of culturally acceptable interventions to underpin care in Tanzania and Zambia.

Design

Mixed‐methods study.

Setting

Tertiary, secondary and primary care facilities in Mansa, Zambia, and Mwanza, Tanzania.

Sample

Quantitative: 1997 women giving birth at two tertiary care facilities (one in each country). Qualitative: 48 women and 19 partners from tertiary, secondary and primary care facilities.

Methods

Case review using data from a target of 2000 consecutive case records. Qualitative interviews with a purposive sample of women and partners, using a grounded theory approach.

Results

A total of 261 stillbirths were recorded, with a rate of 16% in Tanzania and 10% in Zambia, which is higher than the previous estimates of 2.24 and 2.09%, respectively, for those countries. Women in both countries who reported a previous stillbirth were more likely to have stillbirth (RR 1.86, 95% CI 1.23–2.81). The cause of death was unexplained in 28% of cases. Qualitative findings indicated that not knowing what caused the baby to be stillborn prevented women from grieving. This was compounded by the poor communication skills of health professionals, who displayed little empathy and skill when counselling bereaved families.

Conclusions

The stillbirth risk in both facilities was far higher than the risk recorded from national data, with women reporting a previous stillbirth being at higher risk. Women want to know the cause of stillbirth and an exploration of appropriate investigations in this setting is required. Providing health professionals with support and continuing training is key to improving the experiences of women and future care.

Tweetable abstract

Stillbirths receive little investigation and are often unexplained. Communication with women about the death of their baby is limited.

Stillbirths receive little investigation and are often unexplained. Communication with women about the death of their baby is limited.

Stillbirth and fetal anomalies: secondary analysis of a case-control study

OBJECTIVE

Approximately 10% of stillbirths are attributed to fetal anomalies, but anomalies are also common in live births. We aimed to assess the relationship between anomalies, by system and stillbirth.

DESIGN

Secondary analysis of a prospective, case-control study.

SETTING

Multicentre, 59 hospitals in five regional catchment areas in the USA.

POPULATION OR SAMPLE

All stillbirths and representative live birth controls.

METHODS

Standardised postmortem examinations performed in stillbirths, medical record abstraction for stillbirths and live births.

MAIN OUTCOME MEASURES

Incidence of major anomalies, by type, compared between stillbirths and live births with univariable and multivariable analyses using weighted analysis to account for study design and differential consent.

RESULTS

Of 465 singleton stillbirths included, 23.4% had one or more major anomalies compared with 4.3% of 1871 live births. Having an anomaly increased the odds of stillbirth; an increasing number of anomalies was more highly associated with stillbirth. Regardless of organ system affected, the presence of an anomaly increased the odds of stillbirth. These relationships remained significant if stillbirths with known genetic abnormalities were excluded. After multivariable analyses, the adjusted odds ratio (aOR) of stillbirth for any anomaly was 4.33 (95% CI 2.80-6.70) and the systems most strongly associated with stillbirth were cystic hygroma (aOR 29.97, 95% CI 5.85-153.57), and thoracic (aOR16.18, 95% CI 4.30-60.94) and craniofacial (aOR 35.25, 95% CI 9.22-134.68) systems.

CONCLUSIONS

In pregnancies affected by anomalies, the odds of stillbirth are higher with increasing numbers of anomalies. Anomalies of nearly any organ system increased the odds of stillbirth even when adjusting for gestational age and maternal race.

TWEETABLE ABSTRACT

Stillbirth risk increases with anomalies of nearly any organ system and with number of anomalies seen.