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Sharma B, Lahariya C, Majella MG, Upadhyay A, Yadav S, Raina A, Khan T, Aggarwal N. Burden, Differentials and Causes of Stillbirths in India: A Systematic Review and Meta Analysis. Indian J Pediatr 2023; 90:54-62. [PMID: 37556034 DOI: 10.1007/s12098-023-04749-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/22/2023] [Indexed: 08/10/2023]
Abstract
India contributes the highest absolute number of stillbirths in the world. This systematic review and meta-analysis was conducted to synthesize the burden, timing and causes of stillbirths in India. Forty-nine reports from 46 studies conducted in 21 Indian states and Union Territories were included. It was found that there was no uniformity/standardization in the definition of stillbirths and in the classification system used to assign the cause. The share of antepartum stillbirths was estimated to be two-third while remaining were intrapartum stillbirths. Maternal conditions and fetal causes were found to be the leading cause of stillbirth in India. The maternal condition was assigned as the commonest cause (25%) followed by fetal (14%), placental cause (13%), congenital malformation (6%) and intrapartum complications (4%). Approximately 20% of the stillbirths were assigned as unknown or unexplained. This review demonstrates that there is a paucity of quality stillbirth data in India. Other than the state level differences in stillbirth rates, no other data is available on inequities in stillbirths in India. There is an urgent need for strengthening availability and quality of stillbirth data in India on both stillbirth rates as well as the causes. There is a need to conduct additional research to know the timing of the stillbirths, causes of death and actual burden. India needs to strengthen stillbirth audits along with registry to find out the modifiable factors and delays for making country specific preventive strategies. The policy makers, academic community and researchers need to work together to ensure accelerated and equitable reduction in stillbirths in India.
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Affiliation(s)
- Bharti Sharma
- Department of Obstetrics & Gynecology, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India.
| | - Chandrakant Lahariya
- Integrated Department of Health Policy, Epidemiology, Preventive Medicine and Pediatrics, Foundation for People-centric Health Systems, New Delhi, 110029, India
- SD Gupta School of Public Health, The IIHMR University, Jaipur, 302029, India
| | - Marie Gilbert Majella
- Department of Community Medicine, Sri Venkateshwara Medical College Hospital & Research Center, Puducherry, India
| | - Anita Upadhyay
- Director- Projects, Human Capital Lighthouse Consulting Pvt Ltd, New Delhi, 110029, India
| | - Sapna Yadav
- Integrated Department of Health Policy, Epidemiology, Preventive Medicine and Pediatrics, Foundation for People-centric Health Systems, New Delhi, 110029, India
| | - Ankit Raina
- Department of Public Health, Survival for Women & Children (SWACH) Foundation, Panchkula, Haryana, India
| | - Tamkin Khan
- Department of Obstetrics & Gynecology, Aligarh Muslim University, Aligarh, U.P, India
| | - Neelam Aggarwal
- Department of Obstetrics & Gynecology, Postgraduate Institute of Medical Education & Research, Chandigarh, 160012, India
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Kumar M, Puri M, Suka M, Chawla N, Kaur GP, Yadav R, Agrawal K, Biswas R. Impact of Action Taken in Response to Stillbirth Audit: A Success Story. J Obstet Gynaecol India 2023; 73:61-68. [PMID: 37916007 PMCID: PMC10616033 DOI: 10.1007/s13224-023-01808-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/07/2023] [Indexed: 11/03/2023] Open
Abstract
Objectives Study the impact of intra-facility interventions on the modifiable factors causing stillbirths (SB), using point-of-care quality improvement (POCQI) methodology. Material and Methods Stillbirth data during the 9 months pre-intervention period were reviewed to identify the common preventable causes. Two interventions, namely, ultrasound at 34-36 weeks gestation and intrapartum monitoring on a common customized labor chart for all health-care providers, were done. Post-intervention data were collected to observe the impact of the interventions. Results The stillbirth rate reduced from 212/5940 deliveries (35.7/1000) in the pre-intervention period to 165/5993 deliveries (27.7/1000) in the post-intervention period (p = 0.011). The intra-facility failure to identify FGR significantly reduced in the post-intervention group (p = 0.033), leading to 63% (RR 0.37) reduction in its risk. Using a common customized labor chart led to a significant decline in the inadequate monitoring as a provider-related cause of stillbirth (p < 0.001) leading to its 42% decline as contributor to modifiable cause of SB (RR 0.48). Conclusion Reviewing the perinatal death surveillance response (PDSR) data, identifying gaps in care, and using improvement methodology for instituting corrective measures play an important role in reducing intramural stillbirths.
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Affiliation(s)
- Manisha Kumar
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College, Shahid Bhagat Singh Marg, New Delhi, 110001 India
| | - Manju Puri
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College, Shahid Bhagat Singh Marg, New Delhi, 110001 India
| | - Millo Suka
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College, Shahid Bhagat Singh Marg, New Delhi, 110001 India
| | - Nupur Chawla
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College, Shahid Bhagat Singh Marg, New Delhi, 110001 India
| | - Gagan Preet Kaur
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College, Shahid Bhagat Singh Marg, New Delhi, 110001 India
| | - Reena Yadav
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College, Shahid Bhagat Singh Marg, New Delhi, 110001 India
| | - Kiran Agrawal
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College, Shahid Bhagat Singh Marg, New Delhi, 110001 India
| | - Ratna Biswas
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College, Shahid Bhagat Singh Marg, New Delhi, 110001 India
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Marwah S, Jain A, Dabral A, Gupta N. Stillbirth in COVID-19 Affected Pregnancies: A Double Whammy for the Mother. Cureus 2022; 14:e22396. [PMID: 35371732 PMCID: PMC8938211 DOI: 10.7759/cureus.22396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/19/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Pregnant women represent a high-risk group especially during the COVID-19 pandemic, suffering at the expense of pandemic restrictions and landing up in adverse maternofetal outcomes including stillbirth. Fetal demise along with COVID-19 disease acts as a double blow to these mothers. Literature is still limited on its impact on maternofetal outcomes. Methods A prospective, observational study was conducted in a tertiary care hospital in Delhi, India from April 15, 2020 to April 14, 2021, wherein all pregnant mothers with SARS-CoV-2 infection in the hospital who delivered a stillborn baby were enrolled and analyzed for incidence of stillbirth. These women were evaluated for risk factors and causes for stillbirth. Results Out of 15859 deliveries in the institute, there were 330 viable births among COVID-19 affected pregnancies. The incidence of stillbirth was 7.2% (24/330). The institutional delivery rate fell by 43% during the pandemic. The majority of cases were unbooked, from rural areas and of low socioeconomic status (p<0.01). The most significant risk factor and cause for stillbirth was an associated comorbidity (75%, p<0.001), notably severe forms of hypertensive disorders of pregnancy (HDP, 41.6%, p=0.002), followed by preterm labour (58.3%) and preterm premature rupture of membranes (PPROM, 29.1%, p<0.001). HDP remained the main cause of macerated stillbirths while maternal fever (50%, p<0.001) was the main cause of fresh stillbirth. Major modifiable factors were lack of awareness of when to seek care (83.3%), financial reasons (75%), commutation problems (87.5%), distance to hospitals (50%) and delayed referral (41.6%). Conclusion Improved policy-making, with an emphasis on telemedicine, COVID-19 preparedness alongside amped up vaccination and healthcare workers training will help reduce adverse maternofetal outcomes.
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Singh S, Nayak MK, Routray PK, Naik SS, Mohakud NK. Quality Assessment of Stillbirth Review: A Pilot Study in Ten High-Priority Districts in Odisha. Indian J Community Med 2021; 46:430-433. [PMID: 34759481 PMCID: PMC8575215 DOI: 10.4103/ijcm.ijcm_547_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 04/22/2021] [Indexed: 11/14/2022] Open
Abstract
Background: Stillbirth rate has shown less or no improvement in developing countries. India was estimated to have the largest number of stillbirths globally in 2015. Systematic review of stillbirths is a strategy that helps in identifying gaps in the care of a pregnant mother, and is a useful and comprehensive indicator of the quality of maternity care. Objectives: The objective of this study was to assess the quality of maternal care, and factors causing stillbirth, and to provide some doable plans to reduce its incidence in the Odisha state. Materials and Methods: The stillbirth review was undertaken over 4-month timeline (August to November 2014) in ten high-priority districts (HPDs) of Odisha. It included development of tools, desk reviews, training of staffs, and data handling. The deaths were estimated from Annual Health Survey. It was compared to the estimated stillbirth of each district to get the underreporting/overreporting districts. A report was generated on stillbirth process indicators, and program indicators after completion of assessment. Results: In the selected HPDs of Odisha, 4689 stillbirths were observed during the study period. However, the labor room register stated the reason of death in only 408 cases (8.7%). Further, at the time of admission, a provisional diagnosis could be made for only 3038 (64.7%) cases, of which 11% diagnosed as safe delivery resulted in stillbirth. Conclusions: The present study could contribute to a larger extent to address some of the gaps in the stillbirth review process in Odisha.
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Affiliation(s)
- Snigdha Singh
- Department of Community Medicine, KIMS, KIIT Deemed University, Bhubaneswar, Odisha, India
| | - Manas Kumar Nayak
- Department of Pediatrics, KIMS, KIIT Deemed University, Bhubaneswar, Odisha, India
| | - Prashanta Kumar Routray
- Social Department, Kalinga Institute of Social Sciences, Kalinga Institute of Social Sciences University, Bhubaneswar, Odisha, India
| | - Sushree Samiksha Naik
- Department of Obstetrics and Gynecology, Capital Hospital, Bhubaneswar, Odisha, India
| | - Nirmal Kumar Mohakud
- Department of Pediatrics, KIMS, KIIT Deemed University, Bhubaneswar, Odisha, India
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Predictive Model for Late Stillbirth Among Antenatal Hypertensive Women. J Obstet Gynaecol India 2021; 72:96-101. [PMID: 35928077 PMCID: PMC9343536 DOI: 10.1007/s13224-021-01561-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/17/2021] [Indexed: 01/02/2023] Open
Abstract
Objective To develop a predictive model for late stillbirth among women with hypertensive disorders of pregnancy (HDP) in low- and middle-income countries. Materials and Methods Study was part of the WHO newborn birth defect (NBBD) project and included all stillbirths occurring in the facility from November 2015 to December 2020. The age and parity matched subjects with HDP having live birth were taken as controls. All significant predictors were analyzed and a predictive model was developed. Results Out of 69,007 deliveries, 1691(24.5/1000) were stillborn. HDP was seen in (390/1691, 23.0%), in 265/390 (67.4%) cases it occurred at or after 28 weeks of gestation and were included as cases. On comparing the cases with controls, the significant factors were estimated fetal weight less than 2000 gms (P < 0.001, OR 10.3), poor antenatal care (p < 0.001, OR-5.9), family history of hypertension (p < 0.018, OR-4.4) and the presence of gestational hypertension (p = 0.001, OR 2.2). The predictive model had sensitivity and specificity of 80.3% and 70.03%, respectively, the receiver operating curve showed the area under the curve(AUC) in the range of good prediction (0.846). Conclusion The predictive model could play a potential role in stillbirth prevention in women with HDP in low- and middle-income countries. Supplementary Information The online version contains supplementary material available at 10.1007/s13224-021-01561-3.
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Kumar M, Vajala R, Bhutia P, Singh A. Factors contributing to late stillbirth among women with pregnancy hypertension in a developing country. Hypertens Pregnancy 2020; 39:236-242. [PMID: 32396487 DOI: 10.1080/10641955.2020.1757699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To investigate the factors associated with late stillbirth among women with hypertensive disorders of pregnancy (HDP). MATERIAL AND METHODS The clinical details of women with HDP having late stillbirth were compared with controls having livebirth. RESULTS Total 208 cases and 288 controls were included in the study. Inadequate antenatal visits (p < 0.001, OR-5.92). birth weight < 2000 gms (p < 0.001, OR 10.3) and BW/PW ratio > 8 contributed significantly (p = 0.0001, OR-5.6) to stillbirth. CONCLUSION Poor antenatal care, birth weight below 2000gms and high BW/PW ratio was associated with a higher risk of stillbirth.
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Affiliation(s)
- Manisha Kumar
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College , New Delhi, India
| | - Ravi Vajala
- Department of Statistics, Lady Sri Ram College , New Delhi, India
| | - PhunstokDoma Bhutia
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College , New Delhi, India
| | - Abha Singh
- Department of Obstetrics and Gynecology, Lady Hardinge Medical College , New Delhi, India
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Kumar M, Singh A, Garg R, Goel M, Ravi V. Hypertension during pregnancy and risk of stillbirth: challenges in a developing country. J Matern Fetal Neonatal Med 2019; 34:3915-3921. [PMID: 31875739 DOI: 10.1080/14767058.2019.1702943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To explore the factors associated with hypertensive disorders of pregnancy (HDP) in women experiencing stillbirth (SB).Material and methods: It was an observational, analytical case-control study, done as part of the World Health Organization South-East Asian Region Office SB project. The epidemiological profile, history, clinical features, and investigations of stillborn cases having HDP were noted, an equal number of age and parity matched subjects with HDP having livebirth were taken as controls.Results: Out of 46,816 deliveries, 1239 (26.2/1000) were stillborn. The maternal causes contributed 374/1239 (30.2%) stillbirths according to the CODAC classification, HDP was the most common maternal cause (304/1239, 24.9%). Subjects with HDP were included as cases. On comparing the cases with controls it was found that significantly more number of cases had inadequate antenatal visits (p < .001, OR -4.8), two or more abortions (p < .001, OR -1.9), early onset of hypertension (p < .0001, OR -5.6) and complications such as fetal growth restriction (FGR) (p < .001, OR -2.3) and abruption (p < .001, OR -4.0). Women with preeclampsia were less likely to have SB compared to those with gestational or chronic hypertension (p = .0001, OR -2.3). The birth weight/placental weight ratio of more than eight had the highest odds ratio regarding contribution to SB among hypertensive women (p = .0001 OR -6.7).Conclusion: In women with HDP, adequate antenatal care would lead to the prevention of complications such as anemia, abruption, and FGR, and thus prevent SB. The high BW/PW ratio is a potential marker of risk of SB.
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Affiliation(s)
| | - Abha Singh
- Lady Hardinge Medical College, New Delhi, India
| | - Rashi Garg
- Lady Hardinge Medical College, New Delhi, India
| | - Manish Goel
- Lady Hardinge Medical College, New Delhi, India
| | - V Ravi
- Lady Shri Ram College for Women, New Delhi, India
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