Stillbirths: the vision for 2020

International progress on stillbirth reduction: Changes in Stillbirth Rates in Selected Low and Middle-Income Countries from 2000 to 2021

In this paper, we attempted to determine if there were reductions in low and middle - income country stillbirth rates since 2000 - focusing on sub-Saharan Africa, Asia and Latin America and the Caribbean. We used data made available by the United Nations Inter-agency Group for Child Mortality Estimation and the World Health Organization as well as the National Institute of Child Health and Human Development Global Network for Women's and Children's Health Research.. Overall, nearly every country evaluated had at least a small reduction in stillbirth rate from the year 2000 to 2021, but the reductions varied substantially between regions. Asia and Latin America/Caribbean had similar levels of reductions with a number of countries in each of those regions having rates in 2021 that were 40 % or more lower than those documented in 2000. No country in Africa documented a reduction in stillbirths of 40 % and many had stillbirth reductions of less than 15 %.

Incidence and determinants of perinatal mortality in five urban hospitals in Dar es Salaam, Tanzania: a cohort study with an embedded case-control analysis

INTRODUCTION

Tanzania has one of the highest burdens of perinatal mortality, with a higher risk among urban versus rural women. To understand the characteristics of perinatal mortality in urban health facilities, study objectives were: I. To assess the incidence of perinatal deaths in public health facilities in Dar es Salaam and classify these into a) pre-facility stillbirths (absence of fetal heart tones on admission to the study health facilities) and b) intra-facility perinatal deaths before discharge; and II. To identify determinants of perinatal deaths by comparing each of the two groups of perinatal deaths with healthy newborns.

METHODS

This was a retrospective cohort study among women who gave birth in five urban, public health facilities in Dar es Salaam. I. Incidence of perinatal death in the year 2020 was calculated based on routinely collected health facility records and the Perinatal Problem Identification Database. II. An embedded case-control study was conducted within a sub-population of singletons with birthweight ≥ 2000 g (excluding newborns with congenital malformations); pre-facility stillbirths and intra-facility perinatal deaths were compared with 'healthy newborns' (Apgar score ≥ 8 at one and ≥ 9 at five minutes and discharged home alive). Descriptive and logistic regression analyses were performed to explore the determinants of deaths.

RESULTS

A total of 37,787 births were recorded in 2020. The pre-discharge perinatal death rate was 38.3 per 1,000 total births: a stillbirth rate of 27.7 per 1,000 total births and an intra-facility neonatal death rate of 10.9 per 1,000 live births. Pre-facility stillbirths accounted for 88.4% of the stillbirths. The case-control study included 2,224 women (452 pre-facility stillbirths; 287 intra-facility perinatal deaths and 1,485 controls), 99% of whom attended antenatal clinic (75% with more than three visits). Pre-facility stillbirths were associated with low birth weight (cOR 4.40; (95% CI: 3.13-6.18) and with maternal hypertension (cOR 4.72; 95% CI: 3.30-6.76). Intra-facility perinatal deaths were associated with breech presentation (aOR 40.3; 95% CI: 8.75-185.61), complications in the second stage (aOR 20.04; 95% CI: 12.02-33.41), low birth weight (aOR 5.57; 95% CI: 2.62-11.84), cervical dilation crossing the partograph's action line (aOR 4.16; 95% CI:2.29-7.56), and hypertension during intrapartum care (aOR 2.9; 95% CI 1.03-8.14), among other factors.  CONCLUSION: The perinatal death rate in the five urban hospitals was linked to gaps in the quality of antenatal and intrapartum care, in the study health facilities and in lower-level referral clinics. Urgent action is required to implement context-specific interventions and conduct implementation research to strengthen the urban referral system across the entire continuum of care from pregnancy onset to postpartum. The role of hypertensive disorders in pregnancy as a crucial determinant of perinatal deaths emphasizes the complexities of maternal-perinatal health within urban settings.

Care and support when a baby is stillborn: A systematic review and an interpretive meta-synthesis of qualitative studies in high-income countries

INTRODUCTION

Approximately 2 million babies are stillborn annually worldwide, most in low- and middle-income countries. Present review studies of the parental and healthcare providers' experiences of stillbirth often include a variety of settings, which may skew the findings as the available resources can vary considerably. In high-income countries, the prevalence of stillbirth is low, and support programs are often initiated immediately when a baby with no signs of life is detected. There is limited knowledge about what matters to parents, siblings, and healthcare providers when a baby is stillborn in high-income countries.

OBJECTIVES

This systematic review and interpretive meta-synthesis aim to identify important aspects of care and support for parents, siblings, and healthcare professionals in high-income countries from the diagnosis of stillbirth throughout the birth and postpartum period.

METHODS

A systematic review and qualitative meta-synthesis were conducted to gain a deeper and broader understanding of the available knowledge about treatment and support when stillbirth occurred. Relevant papers were identified by systematically searching international electronic databases and citation tracking. The quality of the included studies was assessed, and the data was interpreted and synthesised using Gadamer's hermeneutics. The review protocol, including qualitative and quantitative study approaches, was registered on PROSPERO (CRD42022306655).

RESULTS

Sixteen studies were identified and included in the qualitative meta-synthesis. Experiences of care and support were interpreted and identified as four fusions. First, Personification is of central importance and stresses the need to acknowledge the baby as a unique person. The parents became parents even though their baby was born dead: The staff should also be recognised as the individuals they are with their personal histories. Second, the personification is reinforced by a respectful attitude where the parents are confirmed in their grief; the baby is treated the same way a live baby would be. Healthcare professionals need enough time to process their experiences before caring for other families giving birth. Third, Existential issues about life and death become intensely tangible for everyone involved, and they often feel lonely and vulnerable. Healthcare professionals also reflect on the thin line between life and death and often question their performance, especially when lacking collegial and organisational support. Finally, the fusion Stigmatisation focused on how parents, siblings, and healthcare professionals experienced stigma expressed as a sense of loneliness, vulnerability, and being deviant and marginalised when a baby died before or during birth. GRADE CERQual ratings for the four fusions ranged from moderate to high confidence.

CONCLUSIONS

The profound experiences synthesised in the fusions of this meta-synthesis showed the complex impacts the birth of a baby with no signs of life had on everyone involved. These fusions can be addressed and supported by applying person-centred care to all individuals involved. Hence, grief may be facilitated for parents and siblings, and healthcare professionals may be provided with good conditions in their professional practice. Furthermore, continuing education and support to healthcare professionals may facilitate them to provide compassionate care and support to affected parents and siblings. The fusions should also be considered when implementing national recommendations, guidelines, and clinical practice.

Global Stillbirth Policy Review - Outcomes And Implications Ahead of the 2030 Sustainable Development Goal Agenda

BACKGROUND

Globally, data on stillbirth is limited. A call to action has been issued to governments to address the data gap by strengthening national policies and strategies to drive urgent action on stillbirth reduction. This study aims to understand the policy environment for stillbirths to advance stillbirth recording and reporting in data systems.

METHODS

A systematic three-step process (survey tool examination, identifying relevant study questions, and reviewing country responses to the survey and national documents) was taken to review country responses to the global 2018-2019 World Health Organization (WHO) Reproductive, Maternal, Neonatal, Child and Adolescent Health (RMNCAH) Policy Survey. Policy Survey responses were reviewed to identify if and how stillbirths were included in national documents. This paper uses descriptive analyses to identify and describe the relationship between multiple variables.

RESULTS

Responses from 155 countries to the survey were analysed, and over 800 national policy documents submitted by countries in English reviewed. Fewer than one-fifth of countries have an established stillbirth rate (SBR) target, with higher percentages reported for under-5 (71.0%) and neonatal mortality (68.5%). Two-thirds (65.8%) of countries reported a national maternal death review panel. Less than half (43.9%) of countries have a national policy that requires stillbirths to be reviewed. Two-thirds of countries have a national policy requiring review of neonatal deaths. WHO websites and national health statistics reports are the common data sources for stillbirth estimates. Countries that are signatories to global initiatives on stillbirth reduction have established national targets. Globally, nearly all countries (94.8%) have a national policy that requires every death to be registered. However, 45.5% of reviewed national policy documents made mention of registering stillbirths. Only 5 countries had national policy documents recommending training of health workers in filling out death certificates using the International Classification of Diseases (ICD)-10 for stillbirths.

CONCLUSION

The current policy environment in countries is not supportive for identifying stillbirths and recording causes of death. This is likely to contribute to slow progress in stillbirth reduction. The paper proposes policy recommendations to make every baby count.

Exploring the relationship between intimate partner violence during pregnancy and stillbirths

INTRODUCTION

The relationship between intimate partner violence (IPV) in pregnancy and stillbirths is poorly understood. We aimed to determine if there was any association between stillbirths and IPV during pregnancy.

METHODS

A community-based, matched, case-control study was conducted in 2014, nested within the Maternal and Newborn Health Registry of the Global Network for Women's and Children's Health Research in Pakistan. Using a WHO questionnaire, IPV in pregnancy was ascertained from 256 cases (women with stillbirths) and 539 controls (women with live births), individually matched on parity. Multivariable conditional logistic regression analysis assessed the association of IPV in pregnancy ending in stillbirths compared to those with live births.

RESULTS

The effect of physical and psychological IPV was modified by maternal age. Among women 25-34 years old with stillbirths, the odds of experiencing physical IPV in pregnancy were four times greater than those with live births, after controlling for confounders [odds ratio 4.1 (95% CI: 1.5, 11.2)]. A negative association was observed between psychological IPV in pregnancy and stillbirths among women younger than 25 years, and no association was observed between sexual IPV during pregnancy and stillbirths.

CONCLUSION

Study results show that women 25-34 years of age with stillbirths were four times more likely to experience physical IPV during pregnancy. Further studies replicating the effect modification of IPV by maternal age are warranted.

An approach to determining the most common causes of stillbirth in low and middle-income countries: A commentary

Stillbirth, one of the most common adverse pregnancy outcomes, is especially prevalent in low and middle-income countries (LMICs). Understanding the causes of stillbirth is crucial to developing effective interventions. In this commentary, investigators working across several LMICs discuss the most useful investigations to determine causes of stillbirths in LMICs. Useful data were defined as 1) feasible to obtain accurately and 2) informative to determine or help eliminate a cause of death. Recently, new tools for LMIC settings to determine cause of death in stillbirths, including minimally invasive tissue sampling (MITS) - a method using needle biopsies to obtain internal organ tissue from deceased fetuses for histology and pathogen identification in those tissues have become available. While placental histology has been available for some time, the development of the Amsterdam Criteria in 2016 has provided a useful framework to categorize placental lesions. The authors recommend focusing on the clinical history, the placental evaluation, the external examination of the fetus, and, when available, fetal tissue obtained by MITS, especially of the lung (focused on histology and microbiology) and brain/cerebral spinal fluid (CSF) and fetal blood (focused on microbiological analysis). The authors recognize that this approach may not identify some causes of stillbirth, including some genetic abnormalities and internal organ anomalies, but believe it will identify the most common causes of stillbirth, and most of the preventable causes.

Ending preventable stillbirths and improving bereavement care: a scorecard for high- and upper-middle income countries

BACKGROUND

Despite progress, stillbirth rates in many high- and upper-middle income countries remain high, and the majority of these deaths are preventable. We introduce the Ending Preventable Stillbirths (EPS) Scorecard for High- and Upper Middle-Income Countries, a tool to track progress against the Lancet's 2016 EPS Series Call to Action, fostering transparency, consistency and accountability.

METHODS

The Scorecard for EPS in High- and Upper-Middle Income Countries was adapted from the Scorecard for EPS in Low-Income Countries, which includes 20 indicators to track progress against the eight Call to Action targets. The Scorecard for High- and Upper-Middle Income Countries includes 23 indicators tracking progress against these same Call to Action targets. For this inaugural version of the Scorecard, 13 high- and upper-middle income countries supplied data. Data were collated and compared between and within countries.

RESULTS

Data were complete for 15 of 23 indicators (65%). Five key issues were identified: (1) there is wide variation in stillbirth rates and related perinatal outcomes, (2) definitions of stillbirth and related perinatal outcomes vary widely across countries, (3) data on key risk factors for stillbirth are often missing and equity is not consistently tracked, (4) most countries lack guidelines and targets for critical areas for stillbirth prevention and care after stillbirth and have not set a national stillbirth rate target, and (5) most countries do not have mechanisms in place for reduction of stigma or guidelines around bereavement care.

CONCLUSIONS

This inaugural version of the Scorecard for High- and Upper-Middle Income Countries highlights important gaps in performance indicators for stillbirth both between and within countries. The Scorecard provides a basis for future assessment of progress and can be used to help hold individual countries accountable, especially for reducing stillbirth inequities in disadvantaged groups.

The association between adverse pregnancy outcomes and non-viral genital pathogens among women living in sub-Saharan Africa: a systematic review

Adverse pregnancy outcomes are the main causes of maternal and neonatal morbidity and mortality, including long-term physical and psychological sequelae. These events are common in low- and middle-income countries, particularly in Sub Saharan Africa, despite national efforts. Maternal infections can cause complications at any stage of pregnancy and contribute to adverse outcomes. Among infections, those of the genital tract are a major public health concern worldwide, due to limited availability of prevention, diagnosis and treatment approaches. This applies even to treatable infections and holds true especially in Sub-Saharan Africa. As late as 2017, the region accounted for 40% of all reported treatable non-viral genital pathogens worldwide, many of which have been independently associated with various adverse pregnancy outcomes, and that include Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, Treponema pallidum. Two databases (PubMed and Embase) were examined to identify eligible studies published up to October 2022. This study reviewed findings on the association between infections by treatable non-viral genital pathogens during pregnancy and adverse pregnancy outcomes among women living in Sub-Saharan Africa. Articles' title and abstract were screened at first using keywords as "sexually transmitted infections", "non-viral", "adverse pregnancy outcome", "Africa", "sub-Saharan Africa", "pregnant women", "pregnancy", and "pregnancy outcome". Subsequently, according to the eligibility criteria, potential articles were read in full. Results showed that higher risk of preterm birth is associated with Treponema pallidum, Chlamydia trachomatis and Candida albicans infections. Additionally, rates of stillbirth, neonatal death, low birth weight and intrauterine growth restriction are also associated with Treponema pallidum infection. A better insight on the burden of non-viral genital pathogens and their effect on pregnancy is needed to inform antenatal care guidelines and screening programs, to guide the development of innovative diagnostic tools and other strategies to minimize transmission, and to prevent short- and long-term complications for mothers and children.

Machine learning classification of placental villous infarction, perivillous fibrin deposition, and intervillous thrombus

INTRODUCTION

Placental parenchymal lesions are commonly encountered and carry significant clinical associations. However, they are frequently missed or misclassified by general practice pathologists. Interpretation of pathology slides has emerged as one of the most successful applications of machine learning (ML) in medicine with applications ranging from cancer detection and prognostication to transplant medicine. The goal of this study was to use a whole-slide learning model to identify and classify placental parenchymal lesions including villous infarctions, intervillous thrombi (IVT), and perivillous fibrin deposition (PVFD).

METHODS

We generated whole slide images from placental discs examined at our institution with infarct, IVT, PVFD, or no macroscopic lesion. Slides were analyzed as a set of overlapping patches. We extracted feature vectors from each patch using a pretrained convolutional neural network (EfficientNetV2L). We trained a model to assign attention to each vector and used the attentions as weights to produce a pooled feature vector. The pooled vector was classified as normal or 1 of 3 lesions using a fully connected network. Patch attention was plotted to highlight informative areas of the slide.

RESULTS

Overall balanced accuracy in a test set of held-out slides was 0.86 with receiver-operator characteristic areas under the curve of 0.917-0.993. Cases of PVFD were frequently miscalled as normal or infarcts, the latter possibly due to the perivillous fibrin found at the periphery of infarctions. We used attention maps to further understand some errors, including one most likely due to poor tissue fixation and processing.

DISCUSSION

We used a whole-slide learning paradigm to train models to recognize three of the most common placental parenchymal lesions. We used attention maps to gain insight into model function, which differed from intuitive explanations.

Extended Perinatal Mortality Audit in a Rural Hospital in India

OBJECTIVE

The aim of the study is to describe the status of perinatal mortality (PM) in an Indian rural hospital.

STUDY DESIGN

Retrospective analysis of data was compiled from PM meetings (April 2017 to December 2018) following "Making Every Baby Count: audit and review of stillbirths and neonatal deaths (ENAP or Every Newborn Action Plan)."

RESULTS

The study includes 8,801 livebirths, 105 stillbirths (SBs); 74 antepartum stillbirths [ASBs], 22 intrapartum stillbirths [ISBs], and nine unknown timing stillbirths [USBs]), 39 neonatal deaths or NDs (perinatal death or PDs 144). The higher risks for ASBs were maternal age >34 years, previous history of death, and/or SBs. Almost half of the PDs could be related with antepartum complications. More than half of the ASB were related with preeclampsia/eclampsia and abruptio placentae; one-third of the ISB were related with preeclampsia/eclampsia and gestational hypertension, fetal growth restriction, and placental dysfunction. The main maternal conditions differed between PDs (p = 0.005). The main causes of the ND were infections, congenital malformations, complications of prematurity, intrapartum complications, and unknown. The stillbirth rate was 11.8/1,000 births, neonatal mortality rate 4.4/1,000 livebirths, and perinatal mortality rate 15.8/1,000 births.

CONCLUSION

This is the first study of its kind in Andhra Pradesh being the first step for the analysis and prevention of PM.

KEY POINTS

· Many conditions that lead to stillbirths are linked to neonatal deaths and PM has been outside of the global parameters from the last decades.. · This is the first study following International Classification of Disease perinatal mortality codes and the audit of ENAP in Andhra Pradesh.. · Extended PM and mortality are mainly caused by similar preventable and treatable conditions..

Incidence and causes of stillbirth in the only tertiary referral hospital in the Solomon Islands: a hospital-based retrospective cohort study

OBJECTIVES

Stillbirth is a major global health issue, which disproportionately affects families living in low-income and middle-income countries. The Solomon Islands is a Pacific nation with poor perinatal outcomes, however research investigating stillbirth is lacking. Thus, we aimed to investigate the incidence and cause of stillbirth occurring at the National Referral Hospital, Solomon Islands.

DESIGN

We conducted a retrospective cohort study from January 2017 to December 2018.

SETTING

At the only tertiary referral hospital in the Solomon Islands, on the main island of Guadalcanal.

PARTICIPANTS

All births occurring in the hospital during the study period.

OUTCOME MEASURES

Number of, causes and risk factors for stillbirths (fetal deaths before birth at ≥20 estimated gestational weeks, or ≥500 g in birth weight).

RESULTS

Over 2 years 341 stillbirths and 11 056 total births were recorded, giving an institutional incidence of 31 stillbirths per 1000 births. Of the cases with a recorded cause of death, 72% were deemed preventable. Most stillbirths occurred antenatally and 62% at preterm gestations (<37 weeks). 59% had a birth weight below 2500 g and preventable maternal conditions were present in 42% of the cases. 46% of the cases were caused by an acute intrapartum event, and among these 92% did not receive intrapartum monitoring.

CONCLUSIONS

Stillbirth affects 31 in every 1000 births at the National Referral Hospital in the Solomon Islands and many cases are preventable. Our findings highlight the urgent need for increased focus on perinatal deaths in the Solomon Islands with universal classification and targeted training, improved quality of obstetrical care and community awareness.

Mifepristone combined with ethacridine lactate for third-trimester stillbirth induction: a 5-year experience from Shanghai

OBJECTIVE

To review and analyze the efficacy and safety of mifepristone combined with ethacridine lactate for induction of stillbirth in the third trimester.

METHODS

All patients with stillbirth in late pregnancy (≥ 28 weeks) in a university-affiliated maternity center from October 2016 to September 2021 were included in this study. After exclusion, patients were divided into ethacridine lactate and non-ethacridine lactate groups according to induction methods. Logistic regression was conducted to identify the risks of complications.

RESULTS

We identified 122 patients that experienced stillbirth (5' Apgar score = 0) in third-trimester from the 5-year total deliveries in the hospital, among whom 39 stillbirths that resulted from termination of pregnancy for severe fetal anomalies and 1 stillbirth that was in twin pregnancy were excluded. Thus, 82 cases with stillbirths (dead before induction) were included in the analyses. In the 82 cases, 49 (59.76%) accepted intra-amniotic ethacridine lactate induction with 47 (95.92%, 47/49) successfully induced. No statistical difference was observed in induction failure rate between ethacridine dosage groups of < 75mg and ≥ 75mg (0/25, vs. 2/24, respectively; P > 0.05). The ethacridine lactate induction group showed no increased risks in complications (6.12%, 3/49), compared with non-ethacridine lactate group (12.12%, 4/33) (P = 0.35, OR, 0.47, 95%CI, 0.10 to 2.27).

CONCLUSION

Mifepristone combined with ethacridine lactate is a safe and low-risk induction method for patients with stillbirth in the third trimester.

Association of malaria and curable sexually transmitted infections with pregnancy outcomes in rural Burkina Faso

BACKGROUND

Malaria and curable sexually transmitted infections (STIs) are severe infections associated with poor pregnancy outcomes in sub-Saharan countries. These infections are responsible for low birth weight, preterm birth, and miscarriage. In Burkina Faso, many interventions recommended by the World Health Organization were implemented to control the impact of these infections. After decades of intervention, we assessed the impact of these infections on pregnancy outcomes in rural setting of Burkina Faso.

METHODS

Antenatal care and delivery data of pregnant women attending health facilities in 2016 and 2017 were collected in two rural districts namely Nanoro and Yako, in Burkina Faso. Regression models with likelihood ratio test were used to assess the association between infections and pregnancy outcomes.

RESULTS

During the two years, 31639 pregnant women received antenatal care. Malaria without STI, STI without malaria, and their coinfections were reported for 7359 (23.3%), 881 (2.8 %), and 388 (1.2%) women, respectively. Low birth weight, miscarriage, and stillbirth were observed in 2754 (10.5 %), 547 (2.0 %), and 373 (1.3 %) women, respectively. Our data did not show an association between low birth weight and malaria [Adjusted OR: 0.91 (0.78 - 1.07)], STIs [Adjusted OR: 0.74 (0.51 - 1.07)] and coinfection [Adjusted OR: 1.15 (0.75 - 1.78)]. Low birth weight was strongly associated with primigravidae [Adjusted OR: 3.53 (3.12 - 4.00)]. Both miscarriage and stillbirth were associated with malaria [Adjusted OR: 1.31 (1.07 - 1.59)], curable STI [Adjusted OR: 1.65 (1.06 - 2.59)], and coinfection [Adjusted OR: 2.00 (1.13 - 3.52)].

CONCLUSION

Poor pregnancy outcomes remained frequent in rural Burkina Faso. Malaria, curable STIs, and their coinfections were associated with both miscarriage and stillbirth in rural Burkina. More effort should be done to reduce the proportion of pregnancies lost associated with these curable infections by targeting interventions in primigravidae women.

Building on momentum from the global campaigns: an exploration of factors that influenced prioritization of stillbirth prevention at the national level in Uganda

BACKGROUND

Of the close to 2.6 million stillbirths that happen annually, most are from low-income countries where until recently policies rarely paid special attention to addressing them. The global campaigns that followed called on countries to implement strategies addressing stillbirths and the adoption of recommendations varied according to contexts. This study explored factors that influenced the prioritization of stillbirth reduction in Uganda.

METHODS

The study employed an exploratory qualitative design adopting Shiffman's framework for political prioritization. Data collection methods included a document review and key informants' interviews with a purposively selected sample of 20 participants from the policy community. Atlas. Ti software was used for data management while thematic analysis was conducted to analyze the findings.

FINDINGS

Political prioritization of stillbirth interventions gained momentum following norm promotion from the global campaigns which peaked during the 2011 Lancet stillbirth series. This was followed by funding and technical support of various projects in Uganda. A combination of domestic advocacy factors such as a cohesive policy community converging around the Maternal and Child Health cluster accelerated the process by vetting the evidence and refining recommendations to support the adoption of the policy. The government's health systems strengthening aspirations and integration of interventions to address stillbirths within the overall Maternal and Child Health programming resonated well.

CONCLUSIONS

The transnational influence played a key role during the initial stages of raising attention to the problem and provision of technical and financial support. The success and subsequent processes, however, relied heavily on domestic advocacy and the national political environment, and the cohesive policy community.

Maternity Healthcare Chaplains and Perinatal Post-Mortem Support and Understanding in the United Kingdom and Ireland: An Exploratory Study

Perinatal autopsy rates have declined significantly in recent decades. There is a lack of consensus concerning the potential religious influences for bereaved parents in their decision making process for post-mortem. This online study of British and Irish maternity healthcare chaplains explored their understanding of general and local perinatal post-mortem procedures and their experiences in the support of parents. Participants included Christian, Muslim and non-faith chaplains. No chaplain identified any religious prohibition to perinatal post-mortem. A majority of chaplains reported that they had been asked about post-mortem by parents; only a minority felt adequately prepared. A key recommendation is that following appropriate training chaplains may be well placed to support colleagues and parents during the decision making process.

Residential proximity to roadways and placental-associated stillbirth: a case-control study

We conducted a retrospective case-control study of 1,097 women in Massachusetts and Rhode Island, USA, to examine the association between stillbirth related to placental abruption or placental insufficiency and maternal exposure to traffic-related air pollution. We utilized distance to nearest roadway proximity metrics as a proxy for traffic-related air pollution exposure. No meaningful increase in the overall odds of placental-associated stillbirths was observed (adjusted OR: 1.1, 95% CI: 0.5-2.8). However, mothers living within 50 m of a roadway had a 60% increased odds of experiencing a stillbirth related to placental abruption compared to mothers living greater than 200 m away. This suggestive finding was imprecise due to the small case number in the highest exposure category (95% CI: 0.6-4.0). Future studies of placental abruption with more precise exposure assessments are warranted.

Trends in infant mortality and stillbirth rates in Scotland by socio-economic position, 2000-2018: a longitudinal ecological study

BACKGROUND

As Scotland strives to become a country where children flourish in their early years, it is faced with the challenge of socio-economic health inequalities, which are at risk of widening amidst austerity policies. The aim of this study was to explore trends in infant mortality rates (IMR) and stillbirth rates by socio-economic position (SEP) in Scotland, between 2000 and 2018, inclusive.

METHODS

Data for live births, infant deaths, and stillbirths between 2000 and 2018 were obtained from National Records of Scotland. Annual IMR and stillbirth rates were calculated and visualised for all of Scotland and when stratified by SEP. Negative binomial regression models were used to estimate the association between SEP and infant mortality and stillbirth events, and to assess for break points in trends over time. The slope (SII) and relative (RII) index of inequality compared absolute and relative socio-economic inequalities in IMR and stillbirth rates before and after 2010.

RESULTS

IMR fell from 5.7 to 3.2 deaths per 1000 live births between 2000 and 2018, with no change in trend identified. Stillbirth rates were relatively static between 2000 and 2008 but experienced accelerated reduction from 2009 onwards. When stratified by SEP, inequalities in IMR and stillbirth rates persisted throughout the study and were greatest amongst the sub-group of post-neonates. Although comparison of the SII and RII in IMR and stillbirths before and after 2010 suggested that inequalities remained stable, descriptive trends in mortality rates displayed a 3-year rise in the most deprived quintiles from 2016 onwards.

CONCLUSION

Whilst Scotland has experienced downward trends in IMR and stillbirth rates between 2000 and 2018, the persistence of socio-economic inequalities and suggestion that mortality rates amongst the most deprived groups may be worsening warrants further action to improve maternal health and strengthen support for families with young children.

The CErebro Placental RAtio as indicator for delivery following perception of reduced fetal movements, protocol for an international cluster randomised clinical trial; the CEPRA study

Background

Routine assessment in (near) term pregnancy is often inaccurate for the identification of fetuses who are mild to moderately compromised due to placental insufficiency and are at risk of adverse outcomes, especially when fetal size is seemingly within normal range for gestational age. Although biometric measurements and cardiotocography are frequently used, it is known that these techniques have low sensitivity and specificity. In clinical practice this diagnostic uncertainty results in considerable ‘over treatment’ of women with healthy fetuses whilst truly compromised fetuses remain unidentified. The CPR is the ratio of the umbilical artery pulsatility index over the middle cerebral artery pulsatility index. A low CPR reflects fetal redistribution and is thought to be indicative of placental insufficiency independent of actual fetal size, and a marker of adverse outcomes. Its utility as an indicator for delivery in women with reduced fetal movements (RFM) is unknown. The aim of this study is to assess whether expedited delivery of women with RFM identified as high risk on the basis of a low CPR improves neonatal outcomes. Secondary aims include childhood outcomes, maternal obstetric outcomes, and the predictive value of biomarkers for adverse outcomes.

Methods

International multicentre cluster randomised trial of women with singleton pregnancies with RFM at term, randomised to either an open or concealed arm. Only women with an estimated fetal weight ≥ 10th centile, a fetus in cephalic presentation and normal cardiotocograph are eligible and after informed consent the CPR will be measured. Expedited delivery is recommended in women with a low CPR in the open arm. Women in the concealed arm will not have their CPR results revealed and will receive routine clinical care. The intended sample size based on the primary outcome is 2160 patients. The primary outcome is a composite of: stillbirth, neonatal mortality, Apgar score < 7 at 5 min, cord pH < 7.10, emergency delivery for fetal distress, and severe neonatal morbidity.

Discussion

The CEPRA trial will identify whether the CPR is a good indicator for delivery in women with perceived reduced fetal movements.

Trial registration

Dutch trial registry (NTR), trial NL7557. Registered 25 February 2019.

Developing a core outcome set in interventions to prevent stillbirth: A systematic review on variations of outcome reporting

OBJECTIVE

To determine which outcomes have been previously reported in previous stillbirth prevention studies.

RESEARCH DESIGN

Systematic review of reviews: We searched the Cochrane Database of Systematic Reviews, EMBASE and Pubmed for systematic reviews and meta- analyses investigating interventions to prevent stillbirth and its major risk factors.

DATA COLLECTION AND ANALYSIS

Two reviewers identified and extracted outcomes independently. Outcomes were categorised under relevant domains for analysis. Frequency of each outcome was also determined.

MAIN RESULTS

From 51 eligible reviews, 16 reviews addressed stillbirth prevention specifically while 35 reviews evaluated the efficacies of prevention or management of the eight major risk factors of stillbirth. Two hundred and thirty-seven outcomes were extracted, including 150 maternal outcomes and 87 offspring outcomes. Stillbirth (35/51), perinatal mortality (34/51) and neonatal mortality (33/51) were the most commonly reported outcomes followed by birthweight (29/51), caesarean section (28/51) and preeclampsia/eclampsia (23/51). Self-reported mother/family focused outcomes on their experiences and views were reported in 10/51 reviews.

CONCLUSION

In studies evaluating prevention of stillbirth there is a large variety in outcomes, with discrepancies in nomenclature and measurements. Woman/family-centred outcomes are often missing from studies. There is a need for a core outcome sets agreed by all stakeholders containing the recommended minimum data to be reported in future studies investigating prevention of stillbirth.

Stillbirth in Australia 1: The road to now: Two decades of stillbirth research and advocacy in Australia

Stillbirth is a major public health problem with an enormous mortality burden and psychosocial impact on parents, families and the wider community both globally and in Australia. In 2015, Australia's late gestation stillbirth rate was over 30% higher than that of the best-performing countries globally, highlighting the urgent need for action. We present an overview of the foundations which led to the establishment of Australia's NHMRC Centre of Research Excellence in Stillbirth (Stillbirth CRE) in 2017 and highlight key activities in the following areas: Opportunities to expand and improve collaborations between research teams; Supporting the conduct and development of innovative, high quality, collaborative research that incorporates a strong parent voice; Promoting effective translation of research into health policy and/or practice; and the Regional and global work of the Stillbirth CRE. We highlight the first-ever Senate Inquiry into Stillbirth in Australia in 2018. These events ultimately led to the development of a National Stillbirth Action and Implementation Plan for Australia with the aims of reducing stillbirth rates by 20% over the next five years, reducing the disparity in stillbirth rates between advantaged and disadvantaged communities, and improving care for all families who experience this loss.

Antenatal interventions for preventing stillbirth, fetal loss and perinatal death: an overview of Cochrane systematic reviews

BACKGROUND

Stillbirth is generally defined as a death prior to birth at or after 22 weeks' gestation. It remains a major public health concern globally. Antenatal interventions may reduce stillbirths and improve maternal and neonatal outcomes in settings with high rates of stillbirth. There are several key antenatal strategies that aim to prevent stillbirth including nutrition, and prevention and management of infections.

OBJECTIVES

To summarise the evidence from Cochrane systematic reviews on the effects of antenatal interventions for preventing stillbirth for low risk or unselected populations of women.

METHODS

We collaborated with Cochrane Pregnancy and Childbirth's Information Specialist to identify all their published reviews that specified or reported stillbirth; and we searched the Cochrane Database of Systematic Reviews (search date: 29 Feburary 2020) to identify reviews published within other Cochrane groups. The primary outcome measure was stillbirth but in the absence of stillbirth data, we used perinatal mortality (both stillbirth and death in the first week of life), fetal loss or fetal death as outcomes. Two review authors independently evaluated reviews for inclusion, extracted data and assessed quality of evidence using AMSTAR (A Measurement Tool to Assess Reviews) and GRADE tools. We assigned interventions to categories with graphic icons to classify the effectiveness of interventions as: clear evidence of benefit or harm; clear evidence of no effect or equivalence; possible benefit or harm; or unknown benefit or harm or no effect or equivalence.

MAIN RESULTS

We identified 43 Cochrane Reviews that included interventions in pregnant women with the potential for preventing stillbirth; all of the included reviews reported our primary outcome 'stillbirth' or in the absence of stillbirth, 'perinatal death' or 'fetal loss/fetal death'. AMSTAR quality was high in 40 reviews with scores ranging from 8 to 11 and moderate in three reviews with a score of 7. Nutrition interventions Clear evidence of benefit: balanced energy/protein supplementation versus no supplementation suggests a probable reduction in stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94, 5 randomised controlled trials (RCTs), 3408 women; moderate-certainty evidence). Clear evidence of no effect or equivalence for stillbirth or perinatal death: vitamin A alone versus placebo or no treatment; and multiple micronutrients with iron and folic acid versus iron with or without folic acid. Unknown benefit or harm or no effect or equivalence: for all other nutrition interventions examined the effects were uncertain. Prevention and management of infections Possible benefit for fetal loss or death: insecticide-treated anti-malarial nets versus no nets (RR 0.67, 95% CI 0.47 to 0.97, 4 RCTs; low-certainty). Unknown evidence of no effect or equivalence: drugs for preventing malaria (stillbirth RR 1.02, 95% CI 0.76 to 1.36, 5 RCTs, 7130 women, moderate certainty in women of all parity; perinatal death RR 1.24, 95% CI 0.94 to 1.63, 4 RCTs, 5216 women, moderate-certainty in women of all parity). Prevention, detection and management of other morbidities Clear evidence of benefit: the following interventions suggest a reduction: midwife-led models of care in settings where the midwife is the primary healthcare provider particularly for low-risk pregnant women (overall fetal loss/neonatal death reduction RR 0.84, 95% CI 0.71 to 0.99, 13 RCTs, 17,561 women; high-certainty), training versus not training traditional birth attendants in rural populations of low- and middle-income countries (stillbirth reduction odds ratio (OR) 0.69, 95% CI 0.57 to 0.83, 1 RCT, 18,699 women, moderate-certainty; perinatal death reduction OR 0.70, 95% CI 0.59 to 0.83, 1 RCT, 18,699 women, moderate-certainty). Clear evidence of harm: a reduced number of antenatal care visits probably results in an increase in perinatal death (RR 1.14 95% CI 1.00 to 1.31, 5 RCTs, 56,431 women; moderate-certainty evidence). Clear evidence of no effect or equivalence: there was evidence of no effect in the risk of stillbirth/fetal loss or perinatal death for the following interventions and comparisons: psychosocial interventions; and providing case notes to women. Possible benefit: community-based intervention packages (including community support groups/women's groups, community mobilisation and home visitation, or training traditional birth attendants who made home visits) may result in a reduction of stillbirth (RR 0.81, 95% CI 0.73 to 0.91, 15 RCTs, 201,181 women; low-certainty) and perinatal death (RR 0.78, 95% CI 0.70 to 0.86, 17 RCTs, 282,327 women; low-certainty). Unknown benefit or harm or no effect or equivalence: the effects were uncertain for other interventions examined. Screening and management of fetal growth and well-being Clear evidence of benefit: computerised antenatal cardiotocography for assessing infant's well-being in utero compared with traditional antenatal cardiotocography (perinatal mortality reduction RR 0.20, 95% CI 0.04 to 0.88, 2 RCTs, 469 women; moderate-certainty). Unknown benefit or harm or no effect or equivalence: the effects were uncertain for other interventions examined.

AUTHORS' CONCLUSIONS

While most interventions were unable to demonstrate a clear effect in reducing stillbirth or perinatal death, several interventions suggested a clear benefit, such as balanced energy/protein supplements, midwife-led models of care, training versus not training traditional birth attendants, and antenatal cardiotocography. Possible benefits were also observed for insecticide-treated anti-malarial nets and community-based intervention packages, whereas a reduced number of antenatal care visits were shown to be harmful. However, there was variation in the effectiveness of interventions across different settings, indicating the need to carefully understand the context in which these interventions were tested. Further high-quality RCTs are needed to evaluate the effects of antenatal preventive interventions and which approaches are most effective to reduce the risk of stillbirth. Stillbirth (or fetal death), perinatal and neonatal death need to be reported separately in future RCTs of antenatal interventions to allow assessment of different interventions on these rare but important outcomes and they need to clearly define the target populations of women where the intervention is most likely to be of benefit. As the high burden of stillbirths occurs in low- and middle-income countries, further high-quality trials need to be conducted in these settings as a priority.

Stillbirth 2010-2018: a prospective, population-based, multi-country study from the Global Network

BACKGROUND

Stillbirth rates are high and represent a substantial proportion of the under-5 mortality in low and middle-income countries (LMIC). In LMIC, where nearly 98% of stillbirths worldwide occur, few population-based studies have documented cause of stillbirths or the trends in rate of stillbirth over time.

METHODS

We undertook a prospective, population-based multi-country research study of all pregnant women in defined geographic areas across 7 sites in low-resource settings (Kenya, Zambia, Democratic Republic of Congo, India, Pakistan, and Guatemala). Staff collected demographic and health care characteristics with outcomes obtained at delivery. Cause of stillbirth was assigned by algorithm.

RESULTS

From 2010 through 2018, 573,148 women were enrolled with delivery data obtained. Of the 552,547 births that reached 500 g or 20 weeks gestation, 15,604 were stillbirths; a rate of 28.2 stillbirths per 1000 births. The stillbirth rates were 19.3 in the Guatemala site, 23.8 in the African sites, and 33.3 in the Asian sites. Specifically, stillbirth rates were highest in the Pakistan site, which also documented a substantial decrease in stillbirth rates over the study period, from 56.0 per 1000 (95% CI 51.0, 61.0) in 2010 to 44.4 per 1000 (95% CI 39.1, 49.7) in 2018. The Nagpur, India site also documented a substantial decrease in stillbirths from 32.5 (95% CI 29.0, 36.1) to 16.9 (95% CI 13.9, 19.9) per 1000 in 2018; however, other sites had only small declines in stillbirth over the same period. Women who were less educated and older as well as those with less access to antenatal care and with vaginal assisted delivery were at increased risk of stillbirth. The major fetal causes of stillbirth were birth asphyxia (44.0% of stillbirths) and infectious causes (22.2%). The maternal conditions that were observed among those with stillbirth were obstructed or prolonged labor, antepartum hemorrhage and maternal infections.

CONCLUSIONS

Over the study period, stillbirth rates have remained relatively high across all sites. With the exceptions of the Pakistan and Nagpur sites, Global Network sites did not observe substantial changes in their stillbirth rates. Women who were less educated and had less access to antenatal and obstetric care remained at the highest burden of stillbirth.

STUDY REGISTRATION

Clinicaltrials.gov (ID# NCT01073475).

Spatial distribution of stillbirth and associated factors in Ethiopia: a spatial and multilevel analysis

OBJECTIVE

Although the rate of stillbirth has decreased globally, it remains unacceptably high in developing countries. Today, only 10 countries share the burden of more than 65% of the global rate of stillbirth and these include Ethiopia. Ethiopia ranks seventh in terms of high rate of stillbirths. Exploring the spatial distribution of stillbirth is critical to developing successful interventions and monitoring public health programmes. However, there is no study on the spatial distribution and the associated factors of stillbirth in Ethiopia. Therefore, this study aimed to explore the spatial distribution and the associated factors of stillbirth.

METHODS

Secondary data analysis was conducted based on the 2016 Ethiopian Demographic and Health Survey data. A total weighted sample of 11 375 women were included in the analysis. The Bernoulli model was fitted using SaTScan V.9.6 to identify hotspot areas and ArcGIS V.10.6 to explore the spatial distribution of stillbirth. For associated factors, a multilevel binary logistic regression model was fitted using STATA V.14 software. Variables with a p value of less than 0.2 were considered for the multivariable multilevel analysis. In the multivariable multilevel analysis, adjusted OR (AOR) with 95% CI was reported to reveal significantly associated factors of stillbirth.

RESULTS

The spatial analysis showed that stillbirth has significant spatial variation across the country. The SaTScan analysis identified significant primary clusters of stillbirth in the Northeast Somali region (log likelihood ratio (LLR)=13.4, p<0.001) and secondary clusters in the border area of Oromia and Amhara regions (LLR=8.8, p<0.05). In the multilevel analysis, rural residence (AOR=4.83, 95% CI 1.44 to 16.19), primary education (AOR=0.39, 95% CI 0.20 to 0.74), no antenatal care (ANC) visit (AOR=2.77, 95% CI 1.70 to 4.51), caesarean delivery (AOR=5.07, 95% CI 1.65 to 15.58), birth interval <24 months (AOR=1.95, 95% CI 1.20 to 3.10) and height <150 cm (AOR=2.73, 95% CI 1.45 to 4.97) were significantly associated with stillbirth.

CONCLUSION AND RECOMMENDATION

In Ethiopia, stillbirth had significant spatial variations across the country. Residence, maternal stature, preceding birth interval, caesarean delivery, education and ANC visit were significantly associated with stillbirth. Therefore, public health interventions that enhance maternal healthcare service utilisation and maternal education in hotspot areas of stillbirth are crucial to reducing stillbirth in Ethiopia.

Decreasing trend in preterm birth and perinatal mortality, do disparities also decline?

Background

In the Netherlands, several initiatives started after the publication of the PERISTAT findings that showed the perinatal mortality risk was higher than in other European countries. The objective of this study is 1) to report recent trends in perinatal mortality and in intermediate risk groups (preterm birth, congenital anomalies and small for gestational age (SGA)), 2) describing perinatal mortality risk among children born preterm, with congenital anomalies or SGA, and born in maternal high risk groups (parity, age, ethnicity and socio-economic status (SES)).

Methods

A nationwide cohort study in the Netherlands among 996,423 singleton births in 2010–2015 with a gestational age between 24.0 and 42.6 weeks. Trend tests, univariate and multivariable logistic regression analyses were used. We did separate analyses for gestational age subgroups and line of care.

Results

The perinatal mortality rate was 5.0 per 1000 and it decreased significantly from 5.6 in 2010 to 4.6 per 1000 in 2015. Preterm birth significantly declined (6.1% in 2010 to 5.6% in 2015). Analysis by gestational age groups showed that the largest decline in perinatal mortality of 32% was seen at 24–27 weeks of gestation where the risk declined from 497 to 339 per 1000. At term, the decline was 23% from 2.2 to 1.7 per 1000. The smallest decline was 3% between 32 and 36 weeks.

In children with preterm birth, congenital anomalies or SGA, the perinatal mortality risk significantly declined. Main risk factors for perinatal mortality were African ethnicity (adjusted odds ratio (aOR) 2.1 95%CI [1.9–2.4]), maternal age ≥ 40 years (aOR1.9 95%CI [1.7–2.2]) and parity 2⁺ (aOR 1.4 95%CI [1.3–1.5]). Among the (post)term born neonates, there was no significant decline in perinatal mortality in women with low age, low or high SES, non-Western ethnicity and among women who started or delivered under primary care.

Conclusions

There is a decline in preterm birth and in perinatal mortality between 2010 and 2015. The decline in perinatal mortality is both in stillbirths and in neonatal mortality, most prominently among 24–27 weeks and among (post)term births. A possible future target could be deliveries among 32–36 weeks, women with high maternal age or non-Western ethnicity.

UK stillbirth trends in over 11 million births provide no evidence to support effectiveness of Growth Assessment Protocol program

OBJECTIVE

Use of the Growth Assessment Protocol (GAP) has increased internationally under the assumption that it reduces the stillbirth rate. The evidence for this is limited and based largely on an ecological time-trend study. Discordance in the uptake of the GAP program between Scotland and England/Wales enabled us to assess the assertion that implementation of GAP leads to a reduced stillbirth rate.

METHODS

We analyzed data from the National Records for Scotland and the Office for National Statistics on the number of singleton maternities and stillbirths in Scotland and in England and Wales, respectively, from 1 January 2000 to 31 December 2015. National uptake of the GAP program over time in each of the regions was recorded. Stillbirth rate per 1000 maternities was calculated, according to year of delivery, and compared between Scotland and England/Wales.

RESULTS

During the study period, there were 870 632 singleton maternities in Scotland, of which 4243 were stillbirths, and there were 10 469 120 singleton maternities in England and Wales, of which 51 562 were stillbirths. There was a marked difference in uptake of the GAP program between the two regions, with substantially fewer maternity units in Scotland implementing the program. Stillbirth rates were static up to 2010, with a decline thereafter in both regions, to 3.75 (95% CI, 3.25-4.30) per 1000 maternities in Scotland and 4.30 (95% CI, 4.15-4.46) per 1000 maternities in England and Wales in 2015. From 2010 onwards, the decline in Scotland was faster, equating to 48 (95% CI, 47.9-48.1) fewer stillbirths per 100 000 maternities in Scotland than in England and Wales from 2010 to 2015 compared with 2000 to 2009.

CONCLUSIONS

We observed a decline in stillbirth rate in England and Wales, which coincided with implementation of the GAP program. However, a concurrent decline in stillbirth rate was observed in Scotland in the absence of increased implementation of GAP. The secular rates of change in stillbirth rate in England and Wales cannot be used to infer efficacy of the GAP program. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Stillbirth risk prediction using machine learning for a large cohort of births from Western Australia, 1980-2015

Quantification of stillbirth risk has potential to support clinical decision-making. Studies that have attempted to quantify stillbirth risk have been hampered by small event rates, a limited range of predictors that typically exclude obstetric history, lack of validation, and restriction to a single classifier (logistic regression). Consequently, predictive performance remains low, and risk quantification has not been adopted into antenatal practice. The study population consisted of all births to women in Western Australia from 1980 to 2015, excluding terminations. After all exclusions there were 947,025 livebirths and 5,788 stillbirths. Predictive models for stillbirth were developed using multiple machine learning classifiers: regularised logistic regression, decision trees based on classification and regression trees, random forest, extreme gradient boosting (XGBoost), and a multilayer perceptron neural network. We applied 10-fold cross-validation using independent data not used to develop the models. Predictors included maternal socio-demographic characteristics, chronic medical conditions, obstetric complications and family history in both the current and previous pregnancy. In this cohort, 66% of stillbirths were observed for multiparous women. The best performing classifier (XGBoost) predicted 45% (95% CI: 43%, 46%) of stillbirths for all women and 45% (95% CI: 43%, 47%) of stillbirths after the inclusion of previous pregnancy history. Almost half of stillbirths could be potentially identified antenatally based on a combination of current pregnancy complications, congenital anomalies, maternal characteristics, and medical history. Greatest sensitivity is achieved with addition of current pregnancy complications. Ensemble classifiers offered marginal improvement for prediction compared to logistic regression.

Delivery mode for prolonged, obstructed labour resulting in obstetric fistula: a retrospective review of 4396 women in East and Central Africa

OBJECTIVE

To evaluate the mode of delivery and stillbirth rates over time among women with obstetric fistula.

DESIGN

Retrospective record review.

SETTING

Tanzania, Uganda, Kenya, Malawi, Rwanda, Somalia, South Sudan, Zambia and Ethiopia.

POPULATION

A total of 4396 women presenting with obstetric fistulas for repair who delivered previously in facilities between 1990 and 2014.

METHODS

Retrospective review of trends and associations between mode of delivery and stillbirth, focusing on caesarean section (CS), assisted vaginal deliveries and spontaneous vaginal deliveries.

MAIN OUTCOME MEASURES

Mode of delivery, stillbirth.

RESULTS

Out of 4396 women with fistula, 3695 (84.1%) delivered a stillborn baby. Among mothers with fistula giving birth to a stillborn baby, the CS rate (overall 54.8%, 2027/3695) rose from 45% (162/361) in 1990-94 to 64% (331/514) in 2010-14. This increase occurred at the expense of assisted vaginal delivery (overall 18.3%, 676/3695), which declined from 32% (115/361) to 6% (31/514).

CONCLUSIONS

In Eastern and Central Africa, CS is increasingly performed on women with obstructed labour whose babies have already died in utero. Contrary to international recommendations, alternatives such as vacuum extraction, forceps and destructive delivery are decreasingly used. Unless uterine rupture is suspected, CS should be avoided in obstructed labour with intrauterine fetal death to avoid complications related to CS scars in subsequent pregnancies. Increasingly, women with obstetric fistula add a history of unnecessary CS to their already grim experiences of prolonged, obstructed labour and stillbirth.

TWEETABLE ABSTRACT

Caesarean section is increasingly performed in African women with stillbirth treated for obstetric fistula.

Monitoring maternal and newborn health outcomes globally: a brief history of key events and initiatives

OBJECTIVE

Over time, we have seen a major evolution of measurement initiatives, indicators and methods, such that today a wide range of maternal and perinatal indicators are monitored and new indicators are under development. Monitoring global progress in maternal and newborn health outcomes and development has been dominated in recent decades by efforts to set, measure and achieve global goals and targets: the Millennium Development Goals followed by the Sustainable Development Goals. This paper aims to review, reflect and learn on accelerated progress towards global goals and events, including universal health coverage, and better tracking of maternal and newborn health outcomes.

METHODS

We searched for literature of key events and global initiatives over recent decades related to maternal and newborn health. The searches were conducted using PubMed/MEDLINE and the World Health Organization Global Index Medicus.

RESULTS

This paper describes global key events and initiatives over recent decades showing how maternal and neonatal mortality and morbidity, and stillbirths, have been viewed, when they have achieved higher priority on the global agenda, and how they have been measured, monitored and reported. Despite substantial improvements, the enormous maternal and newborn health disparities that persist within and between countries indicate the urgent need to renew the focus on reducing inequities.

CONCLUSION

The review has featured the long story of the progress in monitoring improving maternal and newborn health outcomes, but has also underlined current gaps and significant inequities. The many global initiatives described in this paper have highlighted the magnitude of the problems and have built the political momentum over the years for effectively addressing maternal and newborn health and well-being, with particular focus on improved measurement and monitoring.

My Baby's Movements: a stepped wedge cluster randomised controlled trial to raise maternal awareness of fetal movements during pregnancy study protocol

Background

Stillbirth is a devastating pregnancy outcome that has a profound and lasting impact on women and families. Globally, there are over 2.6 million stillbirths annually and progress in reducing these deaths has been slow. Maternal perception of decreased fetal movements (DFM) is strongly associated with stillbirth. However, maternal awareness of DFM and clinical management of women reporting DFM is often suboptimal. The My Baby’s Movements trial aims to evaluate an intervention package for maternity services including a mobile phone application for women and clinician education (MBM intervention) in reducing late gestation stillbirth rates.

Methods/design

This is a stepped wedge cluster randomised controlled trial with sequential introduction of the MBM intervention to 8 groups of 3–5 hospitals at four-monthly intervals over 3 years.

The target population is women with a singleton pregnancy, without lethal fetal abnormality, attending for antenatal care and clinicians providing maternity care at 26 maternity services in Australia and New Zealand. The primary outcome is stillbirth from 28 weeks’ gestation. Secondary outcomes address: a) neonatal morbidity and mortality; b) maternal psychosocial outcomes and health-seeking behaviour; c) health services utilisation; d) women’s and clinicians’ knowledge of fetal movements; and e) cost. 256,700 births (average of 3170 per hospital) will detect a 30% reduction in stillbirth rates from 3/1000 births to 2/1000 births, assuming a significance level of 5%. Analysis will utilise generalised linear mixed models.

Discussion

Maternal perception of DFM is a marker of an at-risk pregnancy and commonly precedes a stillbirth. MBM offers a simple, inexpensive resource to reduce the number of stillborn babies, and families suffering the distressing consequences of such a loss. This large pragmatic trial will provide evidence on benefits and potential harms of raising awareness of DFM using a mobile phone app.

Trial registration

ACTRN12614000291684. Registered 19 March 2014.

Version

Protocol Version 6.1, February 2018.

Predictors of loss to follow up among patients with type 2 diabetes mellitus attending a private not for profit urban diabetes clinic in Uganda - a descriptive retrospective study

Background

Although the prevalence of type 2 diabetes mellitus is increasing in Uganda, data on loss to follow up (LTFU) of patients in care is scanty. We aimed to estimate proportions of patients LTFU and document associated factors among patients attending a private not for profit urban diabetes clinic in Uganda.

Methods

We conducted a descriptive retrospective study between March and May 2017. We reviewed 1818 out-patient medical records of adults diagnosed with type 2 diabetes mellitus registered between July 2003 and September 2016 at St. Francis Hospital - Nsambya Diabetes clinic in Uganda. Data was extracted on: patients’ registration dates, demographics, socioeconomic status, smoking, glycaemic control, type of treatment, diabetes mellitus complications and last follow-up clinic visit. LTFU was defined as missing collecting medication for six months or more from the date of last clinic visit, excluding situations of death or referral to another clinic. We used Kaplan-Meier technique to estimate time to defaulting medical care after initial registration, log-rank test to test the significance of observed differences between groups. Cox proportional hazards regression model was used to determine predictors of patients’ LTFU rates in hazard ratios (HRs).

Results

Between July 2003 and September 2016, one thousand eight hundred eighteen patients with type 2 diabetes mellitus were followed for 4847.1 person-years. Majority of patients were female 1066/1818 (59%) and 1317/1818 (72%) had poor glycaemic control. Over the 13 years, 1690/1818 (93%) patients were LTFU, giving a LTFU rate of 34.9 patients per 100 person-years (95%CI: 33.2–36.6). LTFU was significantly higher among males, younger patients (< 45 years), smokers, patients on dual therapy, lower socioeconomic status, and those with diabetes complications like neuropathy and nephropathy.

Conclusion

We found high proportions of patients LTFU in this diabetes clinic which warrants intervention studies targeting the identified risk factors and strengthening follow up of patients.

Prevalence of stillbirth at the Buea Regional Hospital, Fako Division south-west region, Cameroon

Introduction

The study investigated the prevalence of stillbirth at the Buea regional hospital, by taking cases of pregnant women who attended antenatal clinic(s) and those who did not attend but had their deliveries at the Buea regional hospital. The study specifically estimated the prevalence of stillbirths; identified possible risk factors associated with stillbirths, and determined whether the number of antenatal clinic visits is related to the occurrence of stillbirths-because during antenatal clinic visits, pregnant women are educated on risk factors of stillbirths such as: preterm deliveries; sex of the stillbirth; history of stillbirth; history of abortion(s); what age group of mothers are more likely to have a stillbirth.

Methods

The study was a hospital based retrospective study at the maternity in which there were 3577 deliveries registered at the Buea regional hospital dated May 1^st, 2014 to April 30^th, 2017. With the aid of a checklist data was collected, analysed and presented with the use of tables, pie-charts and bar charts.

Results

The prevalence of stillbirths was 26‰; possible risk factors associated with stillbirths included: preterm deliveries; women aged 20-29 years; history of abortion(s); a history of stillbirth; sex of stillbirths were more of females than males; and insufficient antenatal clinic attendance (≤1 antenatal clinic attendance) had more stillbirths.

Conclusion

The study established that stillbirths can occur in any woman of child-bearing age. possible risk factors associated with stillbirths included: preterm deliveries; women aged 20-29 years; history of abortion(s); a history of stillbirth; gender of stillbirths were more of females than males; and insufficient antenatal clinic attendance (≤1 antenatal clinic attendance) had more stillbirths.

Stillbirths: how should its rate be reported, its disability-adjusted-life-years (DALY), and stillbirths adjusted life expectancy

Background

A 2016 study standardized the definition of stillbirths. It estimated the rate as a proportion of total births. A 2015 paper addressed the problem of disability-adjusted life-years (DALY) for stillbirths. There has been no adjustment of life expectancy at birth to account for stillbirths.

Methods and results

We follow mathematical and computational methods, use algebra to derive relationships, and large databases. We express the rate as a proportion of live births and use this rate to adjust life expectancy at birth for stillbirths. We then use the difference between the traditional life expectancy and stillbirths adjusted life expectancy (SALE) to obtain DALY for stillbirths for 194 countries, the Millennium Development Goal regions, and income groups.

We show defining stillbirths’ rate as a proportion of live births enhances stillbirths’ importance, especially in poorer countries; negates some of its under-statement vis-a-vis neonatal mortality rate, accentuates its decrease; and permits inference about relative magnitudes of stillbirths and neonatal mortality from the two rates. Using it, we derive stillbirths adjusted life expectancy, and suggest it reflects a more complete and accurate measure of comparative life expectancies of different countries. Its difference from the traditional life expectancy is used to measure DALY for stillbirths that totals 165.3 million years worldwide.

Conclusion

Stillbirths almost equals neonatal mortality yet have not received almost equal attention. We hope highlighting them and adjusting life expectancy for it will spur health interventions so that grand convergence of health outcomes in different countries can be more rapidly achieved. We also believe SALE is a more complete and accurate measure of comparative life expectancies.

Electronic supplementary material

The online version of this article (10.1186/s12911-019-0850-8) contains supplementary material, which is available to authorized users.

Prevalence and determinants of stillbirth among women attended deliveries in Aksum General Hospital: a facility based cross-sectional study

Objective

In Ethiopia skilled deliveries are increasing but stillbirth is not reducing as required. However; there are limited numbers of up to date studies done related to stillbirth in the study area. Therefore this was aimed to assess the prevalence and determinants of stillbirth using facility based cross-sectional study among women attended deliveries at Aksum General Hospital in 2018. Systematic random sampling method was used to select 573 study participants from the deliveries attended during the study period. The data was entered into Epi-data version 3.1 and exported to Statistical Package for Social Science version 21 for analysis. Bivariate and multivariable logistic regression analysis were conducted to identify significant predictors and strength of association was measured based on adjusted odds ratio with 95% confidence level and statistical significance was declared at p-value less than 0.05.

Results

The prevalence of stillbirth was 3.68% in this study area. Maternal age 20–35 (AOR = 0.25; 95% CI (0.08, 0.80)), not using partograph (AOR = 8.66; 95% CI (2.88, 26.10)) and gestational age < 37 weeks (AOR = 3.86; 95% CI (1.27, 11.69)) were the independent factors affecting the stillbirth.

Pregnancies with an outcome of fetal death present higher risk of delays in obstetric care: A case-control study

The objective of this study was identify the association between delays in the care provided to pregnant women and the fetal death outcome, in a tertiary reference maternity hospital in the Northeastern Brazil. A case-control study, with 72 cases of fetal death and 144 controls (live births) in women admitted to the Obstetrics Service of the Assis Chateaubriand Teaching Maternity Hospital, in Fortaleza, Ceará. Controls were matched (2:1) by the approximate gestational age of the case. The groups were compared using the three delays model of obstetric care. The Pearson's Chi-square test and the Fisher's exact test were used to compare the groups. P <0.05 was considered statistically significant. The Group with fetal death had a smaller number of prenatal consultations (> 6 consultations: 27.8% in cases, 40.3% in controls, p = 0.003), less risk classification of pregnancy (41.7% vs 55.9%, p = 0.048), less guidance about the health facility for delivery (44.5% vs 64%, p = 0.009), lower frequency of cesarean sections (25.4% vs 65.7%) and higher frequency of hemorrhagic syndromes (33.3% vs 19.4%, p = 0.024) and syphilis (15.3% vs 4.2%, p = 0·004). Variables that persisted significantly associated with fetal death in the logistic regression were: Refusal of assistance (OR = 4.07, IC 95%: 1.08–15.3), Absence or inadequacy of prenatal care (OR = 2.69, IC 95%: 1.07–6.75), Delay in diagnosis (OR = 10.3, IC 95%: 2.58–41.4) and Inadequate patient conduct (OR = 4.88; IC 95%: 1.43–16.6). Despite of having a higher frequency of obstetric complications, gestations with fetal death are more prone to delays in obstetric care.

Factors Associated With Stillbirth Among Pregnant Women in Nepal

OBJECTIVES

Stillbirth is a common adverse pregnancy outcome that represents a distressing and traumatic event for women and their partners. The aim of this study was to identify factors associated with stillbirth in ever-pregnant women in Nepal.

METHODS

This study utilized the individual women's dataset from the Nepal Demographic and Health Survey, conducted in 2016. The dependent variable of interest was whether women had at least 1 stillbirth during their lifetime. The associations between independent variables and the dependent variable of the study were analyzed using a multiple logistic regression model.

RESULTS

Among 8918 ever-pregnant women aged 15-49 years, 488 had experienced at least 1 stillbirth during their lifetime, representing 5.5% of the total. After adjusting each factor for the confounding effects of other factors, maternal age, maternal education, place of residence, and sub-region remained significantly associated with having experienced stillbirth.

CONCLUSIONS

Stillbirth continues to be a major problem among women, especially those with higher maternal age, those who are illiterate, and residents of certain geographical regions. To minimize stillbirth in Nepal, plans and policies should be focused on women with low education levels and residents of rural areas, especially in the western mountain and far-western hill regions.

Voices of the unheard: A qualitative survey exploring bereaved parents experiences of stillbirth stigma

BACKGROUND

Every year, 2.6 million babies are stillborn worldwide. Despite these figures, stillbirth remains a relatively ignored public health issue. The wider literature suggests that this is due to the stigma associated with stillbirth. The stigma of stillbirth is seen as possibly one of the greatest barriers in reducing stagnant stillbirth rates and supporting bereaved parents. However, empirical evidence on the extent, type, and experiences of stillbirth stigma remain scarce.

AIM

This study aimed to explore the stigma experiences of bereaved parents who have endured a stillbirth.

METHODS

An online survey of closed and open-questions with 817 participants (n=796 female; n=17 male) was conducted in high-income countries.

FINDINGS

Based on self-perception, 38% of bereaved parents believed they had been stigmatised due to their stillbirth. Thematic data analysis revealed several themes consistent with Link and Phelan's stigma theory- labelling, stereotyping, status loss and discrimination, separation, and power. One more theme outside of this theory- bereaved parents as agents of change was also discovered.

CONCLUSION

Bereaved parents after stillbirth may experience stigma. Common experiences included feelings of shame, blame, devaluation of motherhood and discrimination. Bereaved parents also reported the silence of stillbirth occurred during their antenatal care with many health care providers not informing them about the possibility of stillbirth. Further research needs to be undertaken to explore further the extent and type of stigma felt by bereaved parents after stillbirth, and how stigma is impacting the health care professional disseminating and distributing resources to pregnant women.

Breaking through the silence in antenatal care: Fetal movement and stillbirth education

BACKGROUND

Fetal movements are a key indicator of fetal health. Research has established significant correlations between altered fetal activity and stillbirth. However, women are generally unaware of this relationship. Providing pregnant women with information about the importance of fetal movements could improve stillbirth rates. However, there are no consistent fetal movements awareness messages globally for pregnant women.

AIMS

This study aimed to explore the antenatal care experiences of Australian mothers who had recently had a live birth to determine their knowledge of fetal movements, the nature and source of that information.

METHODS

An online survey method was used for 428 women who had a live birth and received antenatal care in Australia. Women's knowledge of fetal movements, stillbirth risk, and the sources of this knowledge was explored.

FINDINGS

A large proportion of participants (84.6%; n=362) stated they had been informed by health care professionals of the importance of fetal movements during pregnancy. Open-ended responses indicate that fetal movements messages are often myth based. Awareness that stillbirth occurs was high (95.2%; n=398), although, 65% (n=272) were unable to identify the current incidence of stillbirth in Australia.

CONCLUSION

Women who received antenatal care have high-awareness of fetal movements, but the information they received was inconsistent. Participants knew stillbirth occurred but did not generally indicate they had obtained that knowledge from health care professionals. We recommend a consistent approach to fetal movements messaging throughout pregnancy which focuses on stillbirth prevention.

[Medical simulation as a tool in the training of perinatal professionals]

Though technology plays an increasingly important role in modern health systems, human performance remains a major determinant of safety, effectiveness and efficiency of patient care. This is especially true in the delivery room. Thus, the training of professionals must aim not only for the acquisition of theory and practical skills on an individual basis, but also for the learning of teamwork systematically. Training health professionals with simulation enhances their theoretical knowledge and meets formal requirements in literacy, technical skills and communication. Therefore, we intend to explore how, in perinatal care, training with simulation is actually a key teaching tool in initial education and in perpetuation of knowledge. We will approach three main aspects: individual, collective (team) and the impact of simulation in medical practice. The choice of this educational strategy improves the clinical skills that are required for optimal performance in complex, unpredictable and high-stake environments such as the delivery room. Nonetheless, the long term clinical impact of simulation and whether it's modalities, technical or not, are beneficial to the mother and the newborn are areas still to be explored.

Deaths of women hospitalized for childbirth and abortion, and of their concept, in maternity wards of Brazilian public hospitals

The aim of this cross-sectional hospital-based study of 7,845 pregnancies was to analyze deaths of women hospitalized for childbirth and abortion, and fetal and neonatal deaths, in public hospitals in the cities of São Paulo, Rio de Janeiro and Niteroi (RJ), Brazil, in 2011. Outcomes of the pregnancies were: one maternal death, 498 abortions, 65 fetal deaths, 44 neonatal deaths and 7,291 infant survivors. Data were collected through interviews, medical records and the women's pregnancy records, and from the Mortality Information System (SIM). The study population was described and kappa coefficients of causes of death (from the SIM, and certified by research) and mortality health indicators were estimated. The maternal mortality ratio was 13.6 per 100,000 live births (LB), the fetal death rate was 8.8‰ births and the neonatal mortality rate was 6.0‰ LB. The drug most used to induce abortion was Misoprostol. The main causes of fetal and neonatal deaths were respiratory disorders and maternal factors. Congenital syphilis, diabetes and fetal death of unspecified cause were under-reported in the SIM. Kappa coefficients by chapter were 0.70 (neonatal deaths) and 0.54 (stillbirths). Good quality care in reproductive planning, prenatal care, during labor and at birth will result in prevention of deaths.

Risk of stillbirth among Zambian women with a prior cesarean delivery

OBJECTIVE

Cesarean delivery (CD) may be associated with stillbirth in future pregnancies. We investigated prior CD as a risk factor for stillbirth in Lusaka, Zambia.

METHODS

We conducted a retrospective cohort analysis of women with only one prior pregnancy who delivered between February 1, 2006, and May 31, 2013. We analysed data from the Zambia Electronic Perinatal System. Maternal and infant characteristics were analyzed for association with stillbirth using Pearson's χ² test or the Wilcoxon rank-sum test. We calculated risk ratios for the relationship between stillbirth (antepartum vs intrapartum) and prior CD, with a log Poisson model to adjust for confounding.

RESULTS

Of 57 320 women in our cohort, 1933 (3.4%) reported a prior CD. There were 1012 (1.8%) stillbirths in the no prior CD group and 81 (4.2%) in the prior CD group (P<0.001). In multivariate models adjusting for stillbirth risk factors, prior CD was associated with antepartum (adjusted risk ratio 1.56, 95% confidence interval 1.08-2.24) and intrapartum (adjusted risk ratio 3.26, 95% confidence interval 2.40-4.42) stillbirth compared with no prior CD. The difference between groups was most apparent at 36-37 weeks' gestation (log-rank P<0.001).

CONCLUSION

Prior CD was associated with increased risk of stillbirth. Improved monitoring during labor and safe methods for induction are urgently needed in low-resource settings.

Improving pregnancy outcomes in low- and middle-income countries

This paper reviews the very large discrepancies in pregnancy outcomes between high, low and middle-income countries and then presents the medical causes of maternal mortality, stillbirth and neonatal mortality in low-and middle-income countries. Next, we explore the medical interventions that were associated with the very rapid and very large declines in maternal, fetal and neonatal mortality rates in the last eight decades in high-income countries. The medical interventions likely to achieve similar declines in pregnancy-related mortality in low-income countries are considered. Finally, the quality of providers and the data to be collected necessary to achieve these reductions are discussed. It is emphasized that single interventions are unlikely to achieve important reductions in pregnancy-related mortality. Instead, improving the overall quality of pregnancy-related care across the health-care system will be necessary. The conditions that cause maternal mortality also cause stillbirths and neonatal deaths. Focusing on all three mortalities together is likely to have a larger impact than focusing on one of the mortalities alone.

Elevated outdoor temperatures and risk of stillbirth

Background

The causes of stillbirth are poorly understood, including whether elevated outdoor temperatures increase risk. We assessed the relationship between elevated ambient temperatures and risk of stillbirth by gestational age and cause of death during warm months in a temperate region.

Methods

We performed a case-crossover study of 5047 stillbirths in continental Quebec, Canada, between the months of April through September from 1981 to 2011. Using data on maximum daily temperatures adjusted for relative humidity, we estimated associations with stillbirth, comparing temperatures before fetal death with temperatures on adjacent days. The main outcomes were stillbirth according to age of gestation (term, preterm), and cause of death (undetermined, maternal, placenta/cord/membranes, birth asphyxia, congenital anomaly, other).

Results

Elevated outdoor temperatures the week before the death were more strongly associated with risk of term than preterm stillbirth. Odds of term stillbirth for temperature 28 °C the day before death were 1.16 times greater relative to 20 °C (95% confidence interval, CI 1.02-1.33). Elevated outdoor temperature was associated with stillbirth due to undetermined and maternal causes, but not other causes. Compared with 20 °C, the odds of stillbirth at 28 °C were 1.19 times greater for undetermined causes (95% CI 1.02-1.40) and 1.46 times greater for maternal complications (95% CI 1.03-2.07).

Conclusions

Elevated outdoor temperatures may be a risk factor for term stillbirth, including stillbirth due to undetermined causes or maternal complications.

Práticas sociais de medicalização & humanização no cuidado de mulheres na gestação

Resumo: O objetivo principal do trabalho é analisar como discursos de medicalização & humanização se (re)articulam na atenção primária em saúde e configuram o cuidado pré-natal de mulheres grávidas realizado por equipes de saúde da família. Trata-se de um estudo de caso do tipo único e integrado, com múltiplas unidades de análises e abordagem qualitativa. Foram realizados 17 grupos focais e ouvidos 47 trabalhadores (14 médicos, 19 enfermeiros e 14 cirurgiões-dentistas) que compunham 17 equipes de saúde da família em 16 municípios no Sul do Brasil. O material empírico foi analisado na perspectiva da análise do discurso foucaultiana. As equipes de saúde da família, praticantes da medicina generalista, relataram dificuldades para realizar o cuidado pré-natal das mulheres gestantes, evocando e fortalecendo o discurso da medicalização obstétrica que sua prática deveria enfraquecer. O discurso oficialmente adotado pela humanização, privilegiado no modelo generalista de atenção às mulheres gestantes, segue funcionando como discurso complementar ao da medicalização e da especialização, que prevalece nas práticas relatadas. A ênfase na atenção humanizada à mulher na gestação interfere nas fronteiras dos territórios profissionais e pressupõe renegociação de competências. Esforços de colaboração empreendidos entre as equipes de saúde da família e obstetras não apresentam muito sucesso.

Identification of populations at risk: Stillbirth toolkit for health care providers

BACKGROUND

Maternity care and women's health are measured, in part, by the stillbirth rate of a country. The purposes of this pilot project were to: a) establish a baseline of health care provider knowledge regarding stillbirth risk factors based on geographic distribution (urban/rural) and provider licensure (MD, APRN, PA, CNM) and b) evaluate the utility of a Stillbirth Risk Factor Toolkit and its effects on provider knowledge.

METHODS

Evaluative research using a retrospective pre-posttest survey design was completed. The study setting included primary care clinics (urban [n=25] and rural [n=25]) in Nebraska. Health care providers from N=50 clinics were surveyed about their knowledge of stillbirth risk factors (modifiable and non-modifiable) before and after reading the Toolkit.

RESULTS

Providers were least knowledgeable regarding the definition of stillbirth and the number of weeks' gestation that constitute a stillbirth. Overall, there was no significant difference in baseline knowledge between rural and urban providers. Nearly half (43.8%) found the Toolkit to be very helpful and applicable to their patient population, and 34.8% said they would be very likely to utilize it with their patients. There was a statistically significant increase in knowledge of stillbirth risk factors among all health care providers after reviewing the Toolkit (p<0.001).

CONCLUSIONS

Health providers had varied baseline knowledge about stillbirth. The Toolkit improved provider knowledge, but further research is needed to assess its impact on clinical practice.

Clinical interventions to reduce stillbirths in sub-Saharan Africa: a mathematical model to estimate the potential reduction of stillbirths associated with specific obstetric conditions

OBJECTIVE

Stillbirths are among the most common adverse pregnancy outcomes, with 98% occurring in low-income countries. More than one-third occur in sub-Saharan Africa (SSA). However, the medical conditions causing stillbirths and interventions to reduce stillbirths from these conditions are not well documented. We estimated the reductions in stillbirths possible with combinations of interventions.

DESIGN

We developed a computerised model to estimate the impact of various interventions on stillbirths caused by the most common conditions. The model considered the location of obstetric care (home, clinic or hospital) and each intervention's efficacy, penetration and utilisation. Maternal transfers were also considered.

SETTING AND POPULATION

Pregnancies in SSA in 2012.

METHODS

For each condition, we created a series of scenarios involving different combinations of interventions and modelled their impact on stillbirth rates.

MAIN OUTCOME MEASURES

Stillbirths associated with various maternal and fetal conditions and the percentage reduction with various interventions.

RESULTS

Eight to ten maternal and fetal conditions were responsible for most stillbirths, but none for more than 15%. The most common conditions causing stillbirths in SSA include obstructed labour and uterine rupture, fetal distress and umbilical cord complications, fetal growth restriction, pre-eclampsia/eclampsia, and placental abruption/placenta praevia. Syphilis and malaria contribute smaller numbers. Reducing stillbirths requires appropriate diagnosis and management of each condition, usually including hospital care for monitoring and delivery, often by caesarean section. Maternal syphilis and malaria were the only conditions for which outpatient management alone reduced stillbirth.

CONCLUSIONS

Most stillbirths in low-income countries occur at term and during labour and therefore are preventable by appropriate obstetric care. Management focused on the maternal and fetal conditions that cause stillbirths is necessary to achieve stillbirth rates approaching those found in high-income countries.

TWEETABLE ABSTRACT

Reducing stillbirth incidence requires appropriate management of each causative condition and often caesarean delivery.