Stillbirths: what difference can we make and at what cost?

Translating lessons to reinforce national stillbirth response; multi-stakeholder perspectives regarding priorities and opportunities to deliver quality evidence-based interventions within a limited-resource context in Uganda

BACKGROUND

There is noted increase in attention towards implementation of evidence-based interventions in response to the stillbirth burden in low- and middle-income countries including Uganda. Recent results reporting some of the strategies adopted have tended to focus much attention towards their overall effect on the stillbirth burden. More is needed regarding stakeholder reflections on priorities and opportunities for delivering quality services within a limited resource setting like Uganda. This paper bridges this knowledge gap.

METHODS

Data collection occurred between March and June 2019 at the national level. Qualitative interviews were analysed using a thematic analysis technique.

RESULTS

Identified priorities included; a focus on supportive functions such as the referral system, attention to the demand side component of maternal health services, and improvements in the support supervision particularly focusing on empowering subnational level actors. The need to strengthen the learning for better implementation of strategies which are compatible with context was also reported. A comprehensive and favourable policy environment with the potential to direct implementation of strategies, harnessing the private sector contribution as well as the role of national level champions and patient advocates to amplify national stillbirth reduction efforts for continued visibility and impact were recommended.

CONCLUSION

Great potential exists within the current strategies to address the national stillbirth burden. However, priorities such as improving the supportive functions of MCH service delivery and attention to the demand side need to be pursued more for better service delivery with opportunities including a favourable policy environment primed to better serve the current strategies. This calls for dedicated efforts targeted at addressing gaps within the existing priorities and opportunities for better delivery of national strategies to address the stillbirth burden in Uganda.

Trends and geospatial distribution of stillbirths in Uganda, 2014-2020

INTRODUCTION

Uganda with 17.8 stillbirths per 1,000 deliveries in 2021, is among the countries with a high burden of stillbirths globally. In 2014, Uganda adopted the World Health Organization Every New-born Action Plan (ENAP), which targets < 10 stillbirths per 1,000 deliveries by 2035. Little is known about the trends of stillbirth burden since ENAP was introduced. We assessed the temporal, and spatial distribution of stillbirths, in Uganda, 2014-2020, to inform programming for safe pregnancies and deliveries.

METHODS

We obtained and analysed stillbirth surveillance data from the District Health Information System, 2014-2020. A stillbirth was defined as the death of a foetus > 28 weeks of pregnancy or weighing > 1000 g before or during birth and reported to a health facility. We calculated annual incidence rates of stillbirths per 1,000 deliveries at district, regional, and national levels. We used logistic regression to determine the significance of trends.

RESULTS

The overall national annual incidence of stillbirths decreased from 24/1,000 deliveries in 2014 to 17/1,000 deliveries in 2020. During the same period, reporting rates declined from 71% in 2014 to 46% in 2020. The central region continuously had the highest incidence rate for the past 5 years despite the largest decline (OR = 0.79; CI = 0.77-0.83, P < 0.001) while the eastern region had the smallest decline (OR = 0.59; CI = 0.57-0.61, P < 0.001). Districts with persistently high annual incidence rates of stillbirths (> 30/1000) included Mubende, Kalangala, Hoima, and Nebbi. There was no difference in the reporting rates of the most- vs. least-affected districts.

CONCLUSION

Even with suboptimal reporting, the incidence of stillbirths remained above the national target. Specific areas in the country appear to have particularly high stillbirth rates. We recommend continuous capacity building in managing pregnant women with an emphasis on the most affected districts, and investigation into the reasons for low reporting.

Effect of Maternal and Newborn Care Service Package on Perinatal and Newborn Mortality: A Cluster Randomized Clinical Trial

Importance

In resource-constrained settings where the neonatal mortality rate (NMR) is high due to preventable causes and health systems are underused, community-based interventions can increase newborn survival by improving health care practices.

Objectives

To develop and evaluate the effectiveness of a community-based maternal and newborn care services package to reduce perinatal and neonatal mortality in rural Pakistan.

Design, Setting, and Participants

This cluster randomized clinical trial was conducted between November 1, 2012, and December 31, 2013, in district Rahim Yar Khan in the province of Punjab. A cluster was defined as an administrative union council. Any consenting pregnant resident of the study area, regardless of gestational age, was enrolled. An ongoing pregnancy surveillance system identified 12 529 and 12 333 pregnancies in the intervention and control clusters, respectively; 9410 pregnancies were excluded from analysis due to continuation of pregnancy at the end of the study, loss to follow-up, or miscarriage. Participants were followed up until the 40th postpartum day. Statistical analysis was performed from January to May 2014.

Intervention

A maternal and newborn health pack, training for community- and facility-based health care professionals, and community mobilization through counseling and education sessions.

Main Outcomes and Measures

The primary outcome was perinatal mortality, defined as stillbirths per 1000 births and neonatal death within 7 days per 1000 live births. The secondary outcome was neonatal mortality, defined as death within 28 days of life per 1000 live births. Systematic random sampling was used to allocate 10 clusters each to intervention and control groups. Analysis was conducted on a modified intention-to-treat basis.

Results

For the control group vs the intervention group, the total number of households was 33 188 vs 34 315, the median number of households per cluster was 3092 (IQR, 3018-3467) vs 3469 (IQR, 3019-4075), the total population was 229 155 vs 234 674, the mean (SD) number of residents per household was 6.9 (9.5) vs 6.8 (9.6), the number of males per 100 females (ie, the sex ratio) was 104.2 vs 103.7, and the mean (SD) number of children younger than 5 years per household was 1.0 (4.2) vs 1.0 (4.3). Altogether, 7598 births from conrol clusters and 8017 births from intervention clusters were analyzed. There was no significant difference in perinatal mortality between the intervention and control clusters (rate ratio, 0.86; 95% CI, 0.69-1.08; P = .19). The NMR was lower among the intervention than the control clusters (39.2/1000 live births vs 52.2/1000 live births; rate ratio, 0.75; 95% CI, 0.58-0.95; P = .02). The frequencies of antenatal visits and facility births were similar between the 2 groups. However, clean delivery practices were higher among intervention clusters than control clusters (63.2% [2284 of 3616] vs 13.2% [455 of 3458]; P < .001). Chlorhexidine use was also more common among intervention clusters than control clusters (55.9% [4271 of 7642] vs 0.3% [19 of 7203]; P < .001).

Conclusions and Relevance

This pragmatic cluster randomized clinical trial demonstrated a reduction in NMR that occurred in the background of improved household intrapartum and newborn care practices. However, the effect of the intervention on antenatal visits, facility births, and perinatal mortality rates was inconclusive, highlighting areas requiring further research. Nevertheless, the improvement in NMR underscores the effectiveness of community-based programs in low-resource settings.

Trial Registration

ClinicalTrials.gov Identifier: NCT01751945.

Reproductive outcomes among female health care workers

OBJECTIVE

Occupational exposures may be associated with reproductive health and pregnancy outcomes. This study investigated the association between occupational exposures and reproductive health, pregnancy outcomes, and the lactation period among hospital staff.

MATERIALS AND METHODS

Seven hundred thirty-three female healthcare workers from hospitals affiliated with the Tehran University of Medical Sciences were invited to participate in this cross-sectional study. The measurement method for fertility consequences was self-report. Demographic characteristics, occupational data, medical history, and reproductive history were collected via data collection form. Finally, reproductive outcomes were evaluated in different occupational hazard categories.

RESULT

Chemical exposures (solvents) were a risk factor for stillbirth. Prolonged working hours were associated with spontaneous abortion and breastfeeding periods. Shift workers did not have a higher frequency of reproductive and pregnancy outcomes, but the breastfeeding period was significantly decreased in shift workers. Psychiatric disorders were associated with preterm labour, low birth weight, and stillbirth in sequence with nervousness, depression, and mood disturbance. Furthermore, depression affects the breastfeeding period. Moreover, we found a link between job titles and infertility. In addition, socioeconomic status was related to stillbirth and infertility.

CONCLUSION

The study revealed that chemical and ergonomic exposures have associations with some reproductive outcomes. We also conclude that shift work could adversely affect the breastfeeding period. So, implementing some organizational strategies to control adverse health effects of occupational hazards and modifying shift work and working hours for nursing mothers is recommended.

Effects of community-based interventions for stillbirths in sub-Saharan Africa: a systematic review and meta-analysis

Background

Sub-Saharan Africa (SSA) alone contributed to 42% of global stillbirths in 2019, and the rate of stillbirth reduction has remained slow. There has been an increased uptake of community-based interventions to combat stillbirth in the region, but the effects of these interventions have been poorly assessed. Our objectives were to examine the effect of community-based interventions on stillbirth in SSA.

Methods

In this systematic review and meta-analysis, we searched eight databases (MEDLINE [OvidSP], Embase [OvidSP], Cochrane Central Register of Controlled Trials, Global Health, Science Citation Index and Social Science Citation index [Web of Science Core Collection], CINAHL [EBSCOhost] and Global Index Medicus) and four grey literature sources from January 1, 2000 to July 7, 2023 for relevant studies from SSA. Community-based interventions targeting stillbirths solely or as part of complex interventions, with or without hospital interventions were included, while hospital-only interventions, microcredit schemes and maternity waiting home interventions were excluded. Study quality was assessed using the Cochrane risk of bias and National Heart, Lung and Blood Institute's tools. The study outcome was odds of stillbirth in intervention versus control communities. Pooled odds ratios (ORs) were estimated using random-effects models, and subgroup analyses were performed by intervention type and strategies. Publication bias was evaluated by funnel plot and Egger's test. This study is registered with PROSPERO, CRD42021296623.

Findings

Of the 4223 records identified, seventeen studies from fifteen SSA countries were eligible for inclusion. One study had four arms (community only, hospital only, community and hospital, and control arms), so information was extracted from each arm. Analysis of 13 of the 17 studies which had community-only intervention showed that the odds of stillbirth did not vary significantly between community-based intervention and control groups (OR 0.96; 95% CI 0.78-1.17, I2 = 57%, p ≤ 0.01, n = 63,884). However, analysis of four (out of five) studies that included both community and health facility components found that in comparison with community only interventions, this combination strategy significantly reduced the odds of stillbirth by 17% (OR 0.83; 95% CI 0.79-0.87, I2 = 11%, p = 0.37, n = 244,868), after excluding a study with high risk of bias. The quality of the 17 studies were graded as poor (n = 2), fair (n = 9) and good (n = 6).

Interpretation

Community-based interventions alone, without strengthening the quality and capacity of health facilities, are unlikely to have a substantial effect on reducing stillbirths in SSA.

Funding

Nuffield Department of Population Health, Balliol College, the Clarendon Fund, Medical Research Council.

Molecular Characterization of Genital and Extragenital Lesions With the PlexPCR VHS Assay in Patients Diagnosed With Syphilis

Background

Syphilis diagnosis relies on immunologic markers and clinical protocols. However, syphilitic lesions can be confused with other genital ulcer diseases.

Methods

Using a PlexPCR VHS assay, we analyzed lesion DNA samples from 87 individuals who were clinically diagnosed with early syphilis infection and had at least 1 positive serologic test result. DNA was detected by the PlexPCR VHS multiplex assay and β-globin genes.

Results

Among the participants, 99% (86/87) had a positive rapid treponemal test result. DNA was successfully detected in 91% (79/87) of the lesion samples. PlexPCR VHS identified 5 herpes simplex virus (HSV)/Treponema pallidum coinfections (2 HSV-1 and 3 HSV-2), only T pallidum DNA in 62% (49/79), and only HSV-2 in 12.7% (10/79). While 19% (15/79) were negative for all pathogens, none were varicella zoster virus positive. The PlexPCR VHS had 68.4% agreement with the clinical diagnosis.

Conclusions

Since the PlexPCR VHS detects multiple organisms simultaneously, it can help to confirm actual syphilis and identify other pathogen coinfections or the pathogen causing the ulcer.

Types, reporting and acceptability of community-based interventions for stillbirth prevention in sub-Saharan Africa (SSA): a systematic review

Background

Community-based interventions are increasingly being implemented in Sub-Saharan Africa (SSA) for stillbirth prevention, but the nature of these interventions, their reporting and acceptability are poorly assessed. In addition to understanding their effectiveness, complete reporting of the methods, results and intervention acceptability is essential as it could potentially reduce research waste from replication of inadequately implemented and unacceptable interventions. We conducted a systematic review to investigate these aspects of community-based interventions for preventing stillbirths in SSA.

Methods

In this systematic review, eight databases (MEDLINE(OvidSP), Embase (OvidSP), Cochrane Central Register of Controlled Trials, Global Health, Science Citation Index and Social Science Citation index (Web of Science Core Collection), CINAHL (EBSCOhost) and Global Index Medicus) and four grey literature sources were searched from January 1, 2000 to July 7, 2023 for relevant quantitative and qualitative studies from SSA (PROSPERO-CRD42021296623). Following deduplication, abstract screening and full-text review, studies were included if the interventions were community-based with or without a health facility component. The main outcomes were types of community-based interventions, completeness of intervention reporting using the TIDier (Template for Intervention Description and replication) checklist, and themes related to intervention acceptability identified using a theoretical framework. Study quality was assessed using the Cochrane risk of bias and National Heart, Lung and Blood Institute's tools.

Findings

Thirty-nine reports from thirty-four studies conducted in 18 SSA countries were eligible for inclusion. Four types of interventions were identified: nutritional, infection prevention, access to skilled childbirth attendants and health knowledge/behaviour of women. These interventions were implemented using nine strategies: mHealth (defined as the use of mobile and wireless technologies to support the achievement of health objectives), women's groups, community midwifery, home visits, mass media sensitisation, traditional birth attendant and community volunteer training, community mobilisation and transport vouchers. The completeness of reporting using the TIDier checklist varied across studies with a very low proportion of the included studies reporting the intervention intensity, dosing, tailoring and modification. The quality of the included studies were graded as poor (n = 6), fair (n = 14) and good (n = 18). Though interventions were acceptable, only 4 (out of 7) studies explored women's perceptions, mostly focusing on perceived intervention effects and how they felt, omitting key constructs like ethicality, opportunity cost and burden of participation.

Interpretation

Different community-based interventions have been tried and evaluated for stillbirth prevention in SSA. The reproducibility and implementation scale-up of these interventions may be limited by incomplete intervention descriptions in the published literature. To strengthen impact, it is crucial to holistically explore the acceptability of these interventions among women and their families.

Funding

Clarendon/Balliol/NDPH DPhil scholarship for UGA. MN is funded by a Medical Research Council Transition Support Award (MR/W029294/1).

ASW-Net: Adaptive Spectral Wavelet Network for Accurate Fetal ECG Extraction

Noninvasive fetal ECG (FECG) is of great significance for monitoring fetal health. However, it is challenging to extract FECG signals from the abdominal ECG signal (AECG) due to the complexity of the task: 1) FECG signals are routinely mixed with noise; 2) FECG signals are aliased with maternal ECG signals in the time and frequency domain. To solve such problems, an adaptive spectral wavelet network (ASW-Net) is proposed for FECG extraction, where the adaptive spectral wavelet module, which can improve the computational efficiency by replacing convolution operation with element-wise Hadamard product in the frequency domain, is first developed to extract FECG components with different frequencies; then, the residual attention module is devised to distinguish FECG signals from noise by capturing waveform details; finally, the inverse spectral wavelet module is designed to reconstruct FECG signals from multi-resolution FECG components. Experiments conducted on the benchmarks demonstrate that the proposed ASW-Net outperforms the state-of-the-art methods.

Examining the variations in the implementation of interventions to address stillbirth from the national to subnational levels: experiences from Uganda

Background

The current global burden of stillbirth disproportionately affects regions such as sub-Saharan Africa, where Uganda is located. To respond to this burden, policies made at the national level were diffused from the centre and translated into service delivery at the district level, which is charged with implementation under the decentralization of health services arrangement. Variations emerge whenever policy recommendations are moved from national to subnational levels, with some aspects often lost along the way. Tools are available to facilitate knowledge of determinants of policy and innovation implementation within the healthcare system. However, the extent to which these have been applied to explain variations in implementation of interventions to address stillbirth reduction in Uganda remains scant. The aim of this article was to examine the variations in the implementation of interventions to address stillbirth from the national to the subnational levels in Uganda using the Consolidated Framework for Implementation Research (CFIR).

Methods

The study adopted a qualitative case study design. Data were collected from a purposively selected sample of key informants drawn from both the national and subnational levels. All interviews were conducted in English and transcribed verbatim. ATLAS.ti was used to guide the coding process, which used a codebook developed following the CFIR domains as codes and constructs as sub-codes. Analysis followed a content analysis technique.

Results

National-level factors that favoured implementation of interventions to address stillbirth included the desire to comply with global norms, incentives to improve performance for stillbirth reduction indicators for better comparison with global peers, and clear policy alternatives as process implementation advanced by champions. Variations at the subnational level revealed aspirations to address service delivery gaps which fell within maternal health routine standard of care and ongoing health systems strengthening initiatives. Coalescing existing networks around maternal and child health was a key mobilization factor for advocacy and programming, with a promise that the set targets would be operationalized at the subnational level. The key champions were defined by their official roles within the district health systems, which enhanced accountability. Feedback and reflection were distinguished from the national to subnational through joint assemblies and formal audit reviews, respectively.

Conclusions

A heavy influence of the global events directed national-level adaptation of interventions to address stillbirth. Implementation context at the subnational level led to local adaptation and translation of policy provisions from the national level to suit the context, which to a greater extent explains the variations in the final content of policy provisions delivered.

A retrospective autopsy study of 42 cases of stillbirth in Avicenna Research Institute

BACKGROUND

According to the World Health Organization about 2.6 million deaths were reported worldwide in 2015. More than 98% of stillbirths occur in developing countries. At present, the causes of many cases of stillbirth are unknown due to the lack of necessary data and autopsies in Iran. The aim of this study was to investigate the most plausible cause of stillbirth by evaluating clinical records and autopsies.

METHODS

A cross-sectional study of 42 stillbirth autopsies in Avicenna Research Institute from 2012 to 2019, was conducted. Data were extracted from a checklist prepared by the project researchers. The checklist contains maternal demographic information, medical history and maternal illness, pregnancy risk factors, placenta and stillbirth information. Collected data were reviewed and classified according to the ReCoDe (Relevant Condition at Death) system.

RESULTS

In the present study, based on ReCoDe classification, related causes of 95.2% of stillbirths were identified and 4.8% were in the unclassified group. The most common causes were: Fetal causes (64.3%), umbilical cord (14.3%), placenta (7.1%), amniotic fluid (4.8%), maternal medical conditions (2.4%). The causes of about 70% of stillbirth in Iran are unexplained, but in this study, using autopsy results and ReCoDe classification, only 4.8% of stillbirth causes remained unexplained.

CONCLUSIONS

In our study, unknown cases were rare after autopsy. But considering the limitations and costs of autopsy, we need to design the guideline to specify cases who need an autopsy. Fetal autopsy, placental examination and clinical information could reduce the proportion of stillbirths that remain unexplained.

Knowledge of preconception care among reproductive-age women in Debre Berhan Town, Ethiopia: a community-based, cross-sectional study

OBJECTIVES

Preconception care can have a major public health impact by reducing maternal and childhood mortality and morbidity. Despite this importance, preconception care is still not implemented in majority of developing countries. Therefore, this study aimed to assess the proportion of knowledge of preconception care and its associated factors among reproductive-age women in Debre Berhan Town, Ethiopia.

DESIGN AND METHODS

A community-based, cross-sectional study was employed from 1 March to 30 March 2019 among reproductive-age women. Data were collected via a face-to-face, interviewer-administered questionnaire. Data were entered into EpiData V.4.6 and exported to SPSS V.25 for analysis. In a multivariable logistic regression analysis, variables with p<0.05 were declared statistically significant. The strength of statistical association was measured using adjusted OR (AOR) and 95% CI.

SETTING AND PARTICIPANTS

The study was conducted in Debre Berhan Town, Ethiopia. A total of 414 reproductive-age women were enrolled in the study.

OUTCOME

Knowledge of preconception (good or poor).

RESULTS

Of the total 414 participants, 71 (17.1%) had good knowledge about preconception care. Women's occupation (AOR: 8.68, 95% CI 1.25 to 60.3), monthly income (AOR: 9.89, 95% CI 1.93 to 50.76), gravidity (AOR: 0.28, 95% CI 0.14 to 0.58), contraceptive use (AOR: 4.95, 95% CI 1.09 to 22.39), history of congenital abnormality (AOR: 7.53, 95% CI 2.03 to 27.96), history of neonatal death (AOR: 6.51, 95% CI 1.62 to 26.18) and time to reach a health facility (AOR: 0.37, 95% CI 0.17 to 0.79) were statistically associated with knowledge about preconception care.

CONCLUSIONS

In this study area, only less than one-fifth of reproductive-age women had good knowledge of preconception care. Therefore, to improve women's knowledge about preconception care, a strong collaborative effort including several sectors should be made.

Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a trial-based and model-based cost-effectiveness analysis from a stepped wedge, cluster-randomised trial

Background

The AFFIRM intervention aimed to reduce stillbirth and neonatal deaths by increasing awareness of reduced fetal movements (RFM) and implementing a care pathway when women present with RFM. Although there is uncertainty regarding the clinical effectiveness of the intervention, the aim of this analysis was to evaluate the cost-effectiveness.

Methods

A stepped-wedge, cluster-randomised trial was conducted in thirty-three hospitals in the United Kingdom (UK) and Ireland. All women giving birth at the study sites during the analysis period were included in the study. The costs associated with implementing the intervention were estimated from audits of RFM attendances and electronic healthcare records. Trial data were used to estimate a cost per stillbirth prevented was for AFFIRM versus standard care. A decision analytic model was used to estimate the costs and number of perinatal deaths (stillbirths + early neonatal deaths) prevented if AFFIRM were rolled out across Great Britain for one year. Key assumptions were explored in sensitivity analyses.

Results

Direct costs to implement AFFIRM were an estimated £95,126 per 1,000 births. Compared to standard care, the cost per stillbirth prevented was estimated to be between £86,478 and being dominated (higher costs, no benefit). The estimated healthcare budget impact of implementing AFFIRM across Great Britain was a cost increase of £61,851,400/year.

Conclusions

Perinatal deaths are relatively rare events in the UK which can increase uncertainty in economic evaluations. This evaluation estimated a plausible range of costs to prevent baby deaths which can inform policy decisions in maternity services.

Trial registration

The trial was registered with www.ClinicalTrials.gov, number NCT01777022.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04563-9.

Association of Triglyceride-Glucose Index and Liver Function Parameters Among Healthy Obese Civil Servants: A Center-Based Study

PURPOSE

To investigate the correlation between Triglyceride-glucose (TyG) index and liver function parameters in healthy obese civil servants in Shijiazhuang, China.

MATERIALS AND METHODS

This was an outpatient-based cross-sectional study in which 6452 participants were recruited. A total of 784 participants were analyzed according to inclusion and exclusion criteria. A TyG index was calculated based on fasting glucose and triglycerides. All patients were divided into a high TyG index group and a low TyG index group, using the median TyG index as a cut-off. Finally, patients were further divided into two subgroups: males and females.

RESULTS

While AST/ALT and direct bilirubin levels were lower in the high TyG index group compared to the low TyG index group, ALT, AST, total protein, and albumin levels were greater. Particularly in male participants, TyG index was inversely connected with AST/ALT and direct bilirubin levels and favorably correlated with ALT, AST, total protein, and albumin levels. These connections persisted in the multilinear regression study even after adjusting for confounding variables.

CONCLUSION

This study describes the correlation between TyG index and liver function parameters in obese populations without co-morbid diseases, providing a new idea for early interventional treatment in this group.

Interventions to reduce preterm birth and stillbirth, and improve outcomes for babies born preterm in low- and middle-income countries: A systematic review

BACKGROUND

Reducing preterm birth and stillbirth and improving outcomes for babies born too soon is essential to reduce under-5 mortality globally. In the context of a rapidly evolving evidence base and problems with extrapolating efficacy data from high- to low-income settings, an assessment of the evidence for maternal and newborn interventions specific to low- and middle-income countries (LMICs) is required.

METHODS

A systematic review of the literature was done. We included all studies performed in LMICs since the Every Newborn Action Plan, between 2013 - 2018, which reported on interventions where the outcome assessed was reduction in preterm birth or stillbirth incidence and/or a reduction in preterm infant neonatal mortality. Evidence was categorised according to maternal or neonatal intervention groups and a narrative synthesis conducted.

RESULTS

179 studies (147 primary evidence studies and 32 systematic reviews) were identified in 82 LMICs. 81 studies reported on maternal interventions and 98 reported on neonatal interventions. Interventions in pregnant mothers which resulted in significant reductions in preterm birth and stillbirth were (i) multiple micronutrient supplementation and (ii) enhanced quality of antenatal care. Routine antenatal ultrasound in LMICs increased identification of fetal antenatal conditions but did not reduce stillbirth or preterm birth due to the absence of services to manage these diagnoses. Interventions in pre-term neonates which improved their survival included (i) feeding support including probiotics and (ii) thermal regulation. Improved provision of neonatal resuscitation did not improve pre-term mortality rates, highlighting the importance of post-resuscitation care. Community mobilisation, for example through community education packages, was found to be an effective way of delivering interventions.

CONCLUSIONS

Evidence supports the implementation of several low-cost interventions with the potential to deliver reductions in preterm birth and stillbirth and improve outcomes for preterm babies in LMICs. These, however, must be complemented by overall health systems strengthening to be effective. Quality improvement methodology and learning health systems approaches can provide important means of understanding and tackling implementation challenges within local contexts. Further pragmatic efficacy trials of interventions in LMICs are essential, particularly for interventions not previously tested in these contexts.

A qualitative focus group study concerning perceptions and experiences of Nigerian mothers on stillbirths

Objective

To explore the experiences and perceptions of stillbirth among mothers from a tertiary medical centre in Kano, Northern Nigeria.

Design

Qualitative, interpretative.

Setting

Tertiary healthcare facility, Murtala Muhammad Specialist Hospital (MMSH), Kano, Northern Nigeria.

Sample

Mothers who had given birth to a liveborn baby at the MMSH in the prior 6 months (n = 31). In order to capture the experiences and perception of stillbirth within this cohort we approached mothers who had in a previous pregnancy experienced a stillbirth. Of the 31 who attended 16 had a previous stillbirth.

Methods

Semi-structured Focus Group Discussions, consisting of open-ended questions about stillbirth, beliefs, experiences and influences were held in MMSH, conducted over 1 day.

Results

Our findings highlight that this is a resource-poor tertiary facility serving an ever-growing population, increasing strain on the hospital and healthcare workers. Many of the participants highlighted needing permission from certain family members before accessing healthcare or medical treatment. We identified that mothers generally have knowledge on self-care during pregnancy, yet certain societal factors prevented that from being their priority. Judgement and blame was a common theme, yet a complex area entwined with traditions, superstitions and the pressure to procreate with many mothers described being made to feel useless and worthless if they did not birth a live baby.

Conclusions

As access to healthcare becomes easier, there are certain traditions, family and social dynamics and beliefs which conflict with scientific knowledge and act as a major barrier to uptake of healthcare services. The findings highlight the need for investment in maternity care, appropriate health education and public enlightenment; they will help inform appropriate interventions aimed at reducing stigma around stillbirth and aide in educating mothers about the importance of appropriate health seeking behaviour. Stillbirths are occurring in this area of the world unnecessarily, globally there has been extensive research conducted on stillbirth prevention. This research has highlighted some of the areas which can be tackled by modifying existing successful interventions to work towards reducing preventable stillbirths.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04207-4.

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.

Preventable stillbirths in India and Pakistan: a prospective, observational study

OBJECTIVE

Stillbirths occur 10-20 times more frequently in low-income settings compared with high-income settings. We created a methodology to define the proportion of stillbirths that are potentially preventable in low-income settings and applied it to stillbirths in sites in India and Pakistan.

DESIGN

Prospective observational study.

SETTING

Three maternity hospitals in Davangere, India and a large public hospital in Karachi, Pakistan.

POPULATION

All cases of stillbirth at ≥20 weeks of gestation occurring from July 2018 to February 2020 were screened for participation; 872 stillbirths were included in this analysis.

METHODS

We prospectively defined the conditions and gestational ages that defined the stillbirth cases considered potentially preventable. Informed consent was sought from the parent(s) once the stillbirth was identified, either before or soon after delivery. All information available, including obstetric and medical history, clinical course, fetal heart sounds on admission, the presence of maceration as well as examination of the stillbirth after delivery, histology, and polymerase chain reaction for infectious pathogens of the placenta and various fetal tissues, was used to assess whether a stillbirth was potentially preventable.

MAIN OUTCOME MEASURES

Whether a stillbirth was determined to be potentially preventable and the criteria for assignment to those categories.

RESULTS

Of 984 enrolled, 872 stillbirths at ≥20 weeks of gestation met the inclusion criteria and were included; of these, 55.5% were deemed to be potentially preventable. Of the 649 stillbirths at ≥28 weeks of gestation and ≥1000 g birthweight, 73.5% were considered potentially preventable. The most common conditions associated with a potentially preventable stillbirth at ≥28 weeks of gestation and ≥1000 g birthweight were small for gestational age (SGA) (52.8%), maternal hypertension (50.2%), antepartum haemorrhage (31.4%) and death that occurred after hospital admission (15.7%).

CONCLUSIONS

Most stillbirths in these sites were deemed preventable and were often associated with maternal hypertension, antepartum haemorrhage, SGA and intrapartum demise.

TWEETABLE ABSTRACT

Most stillbirths are preventable by better care for women with hypertension, growth restriction and antepartum haemorrhage.

Prevalence of stillbirth and its associated factors in East Africa: generalized linear mixed modeling

BACKGROUND

Stillbirth is the most frequently reported adverse pregnancy outcome worldwide, which imposes significant psychological and economic consequences to mothers and affected families. East African countries account for one-third of the 2.6 million stillbirths globally. Though stillbirth is a common public health problem in East African countries, there is limited evidence on the pooled prevalence and associated factors of stillbirth in East Africa. Therefore, this study aimed to investigate the prevalence of stillbirth and its associated factors in East Africa.

METHODS

This study was based on the most recent Demographic and Health Surveys (DHSs) of 12 East African countries. A total weighted sample of 138,800 reproductive-age women who gave birth during the study period were included in this study. The prevalence of stillbirth with the 95% Confidence Interval (CI) was reported using a forest plot. A mixed-effect binary logistic regression analysis was done to identify significantly associated factors of stillbirth. Since the DHS data has hierarchical nature, the presence of clustering effect was assessed using the Likelihood Ratio (LR) test, and Intra-cluster Correlation Coefficient (ICC), and deviance were used for model comparison. Variables with a p-value of less than 0.2 in the bi-variable analysis were considered for the multivariable analysis. In the multivariable mixed-effect binary logistic regression analysis, the Adjusted Odds Ratio (AOR) with 95% CI were reported to declare the strength and significance of the association.

RESULTS

The prevalence of stillbirth in East Africa was 0.86% (95% CI: 0.82, 0.91) ranged from 0.39% in Kenya to 2.28% in Burundi. In the mixed-effect analysis; country, women aged 25-34 years (AOR = 1.27, 95% CI: 1.11, 1.45), women aged ≥ 35 years (AOR = 1.19, 95% CI: 1.01, 1.44), poor household wealth (AOR = 1.07, 95% CI: 1.02, 1.23), women who didn't have media exposure (AOR = 1.11, 95% CI: 1.01, 1.25), divorced/widowed/separated marital status (AOR = 2.99, 95% CI: 2.04, 4.39), caesarean delivery (AOR = 1.81, 95% CI: 1.52, 2.15), preceding birth interval < 24 months (AOR = 1.15, 95% CI: 1.06, 1.24), women attained secondary education or above (AOR = 0.68, 95% CI: 0.56, 0.81) and preceding birth interval ≥ 49 months (AOR = 1.45, 95% CI: 1.28, 1.65) were significantly associated with stillbirth.

CONCLUSIONS

Stillbirth remains a major public health problem in East Africa, which varied significantly across countries. These findings highlight the weak health care system of East African countries. Preceding birth interval, county, maternal education media exposure, household wealth status, marital status, and mode of delivery were significantly associated with stillbirth. Therefore, public health programs enhancing maternal education, media access, and optimizing birth spacing should be designed to reduce the incidence of stillbirth.

Modifiable Factors and Delays Associated with Neonatal Deaths and Stillbirths in Jordan: Findings from Facility-Based Neonatal Death and Stillbirth Audits

OBJECTIVE

 This study employed the "three-delay" model to investigate the types of critical delays and modifiable factors that contribute to the neonatal deaths and stillbirths in Jordan.

STUDY DESIGN

 A triangulation research method was followed in this study to present the findings of death review committees (DRCs), which were formally established in five major hospitals across Jordan. The DRCs used a specific death summary form to facilitate identifying the type of delay, if any, and to plan specific actions to prevent future similar deaths. A death case review form with key details was also filled immediately after each death. Moreover, data were collected from patient notes and medical records, and further information about a specific cause of death or the contributing factors, if needed, were collected.

RESULTS

 During the study period (August 1, 2019-February 1, 2020), 10,726 births, 156 neonatal deaths, and 108 stillbirths were registered. A delay in recognizing the need for care and in the decision to seek care (delay 1) was believed to be responsible for 118 (44.6%) deaths. Most common factors included were poor awareness of when to seek care, not recognizing the problem or the danger signs, no or late antenatal care, and financial constraints and concern about the cost of care. Delay 2 (delay in seeking care or reaching care) was responsible for nine (3.4%) cases. Delay 3 (delay in receiving care) was responsible for 81 (30.7%) deaths. The most common modifiable factors were the poor or lack of training that followed by heavy workload, insufficient staff members, and no antenatal documentation. Effective actions were initiated across all the five hospitals in response to the delays to reduce preventable deaths.

CONCLUSION

 The formation of the facility-based DRCs was vital in identifying critical delays and modifiable factors, as well as developing initiatives and actions to address modifiable factors.

KEY POINTS

· Death review committees play key roles in identifying critical delays and modifiable factors.. · The "three-delay" model was successful in identifying preventable neonatal deaths and stillbirths.. · Death review committees are central in developing actions to reduce preventable deaths..

Association between utilization and quality of antenatal care with stillbirths in four tertiary hospitals in a low-income urban setting

INTRODUCTION

About 2.6 million stillbirths per year occur globally with 98% occurring in low- and middle-income countries including Kenya, where an estimated 35 000 stillbirths occur annually. Most studies have focused on the direct causes of stillbirth. The aim of this study was to determine the association between antenatal care utilization and quality with stillbirth in a Kenyan set up. This information is key when planning strategies to reduce the stillbirth burden.

MATERIAL AND METHODS

This was a case-control study in four urban tertiary hospitals carried out between August 2018 and April 2019. A total of 214 women with stillbirths (cases) and 428 with livebirths (controls) between 28 and 42 weeks were enrolled. Information was obtained through interviews and data abstracted from medical records. Antenatal care utilization was assessed by the proportions of women not attending antenatal care; booking first antenatal care visit in first trimester and not making the requisite four antenatal care visits. Quality of antenatal care was assessed using individual surrogate indicators (antenatal profile testing, weight/blood pressure/urinalysis testing in each antenatal visit, utilization of early obstetric ultrasound, completeness of antenatal records) and a codified indicator made up of seven parameters (attending antenatal care, booking first antenatal care in the first trimester, making four or more antenatal visits, having all antenatal profile tests, having a complete antenatal record, having blood pressure and weight measured at all visits). The association between antenatal care utilization and quality with stillbirth was assessed using univariate and multivariate analysis using logistic regression. Statistical significance was defined as a two-tailed P value ≤ .05.

RESULTS

Women with stillbirth were likely to have a parity ≥4 (19.6% vs 12.6%, P = .02), have an obstetric complication (36% vs 8.6%, P = .001) and have a medical disorder (5.6% vs 1.6%, P = .01). The odds of a stillbirth were four times higher among those who did not attend antenatal care ( odds ratio [OR] 4.1, 95% confidence interval [CI] 1.6-10, P < .003). Compared with four antenatal care visits, those who had one or two visits had higher odds of a stillbirth: OR 2.96 (95% CI 1.4-6.1), P = .003, and OR 2.9 (95% CI 1.7-5), P = .003, respectively. As per the individual surrogate indicators, the likelihood of a stillbirth was lower in women who received good quality antenatal care: Hemoglobin testing (OR 0.6, 95% CI 0.4-0.8, P = .03), blood group test (OR 0.4, 95% CI 0.2-0.6, P < .001), HIV test (OR 0.3, 95% CI 0.2-0.5, P = .001), venereal disease research laboratory test (OR 0.2, 95% CI 0.1-0.4, P = .001), weight measurement (OR 0.7, 95% CI 0.5-1.0, P = .047). As per the composite indicator, the quality of antenatal care was poor across the board and there was no association between this surrogate indicator and stillbirth.

CONCLUSIONS

Lack of antenatal care, attending fewer than four antenatal visits and poor quality antenatal care as measured by surrogate indicators were significantly associated with stillbirth. In addition, women with low education level, obstetric complications, multiparity and medical complications had a significantly higher likelihood of stillbirth. Improving the utilization of four or more antenatal visits and the quality of antenatal care can reduce the risk of stillbirth.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Methods

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

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

Conclusions

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

Supplementary Information

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

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.

Could a multidisciplinary regional audit identify avoidable factors and delays that contribute to stillbirths? A retrospective cohort study

Background

The annual rate of stillbirth in Sweden has remained largely unchanged for the past 30 years. In Sweden, there is no national audit system for stillbirths. The aim of the study was to determine if a regional multidisciplinary audit could help in identifying avoidable factors and delays associated with stillbirths.

Methods

Population-based retrospective cohort study.

Settings: Six labour wards in Stockholm County.

Participants: Women delivering a stillbirth > 22 weeks of gestation in Stockholm during 2017.

Intervention: A multidisciplinary team was convened. Each team member independently assessed the medical chart of each case of stillbirth regarding causes and preventability, level of delay, the standard of healthcare provided, the investigation of maternal/foetal diseases and if any recommendations were given for the next pregnancy. A decision was based on the agreement of all five members. If no agreement was reached, a reassessment of the case was done and the medical record was scrutinized again until a mutual decision was made.

Primary outcomes: The frequency of probably/possibly preventable factors associated with a stillbirth and the level of delay (patient/caregiver).

Secondary outcomes: The causes of death, the standard of antenatal/intrapartum/postpartum care, whether a summary of possible causes of the stillbirth was made and if any plans for future pregnancies were noted.

Results

Thirty percent of the stillbirths were assessed as probably/possibly preventable. More frequent ultrasound/clinical check-ups, earlier induction of labour and earlier interventions in line with current guidelines were identified as possibly preventable factors. A possibly preventable stillbirth was more common among non-Swedish-speaking women (p = 0.03). In 15% of the cases, a delay by the healthcare system was identified. Having multiple caregivers, absence of continuity in terms of attending the antenatal clinic and not following the basic monitoring program for antenatal care were also identified as risk factors for a delay.

Conclusion

A national/regional multidisciplinary audit group retrospectively identified factors associated with stillbirth. Access to good translation services or a more innovative approach to the problem regarding communication with mothers could be an important factor to decrease possible patient delays contributing to stillbirths.

Trial registration

NCT04281368.

Rate, determinants, and causes of stillbirth in Jordan: Findings from the Jordan Stillbirth and Neonatal Deaths Surveillance (JSANDS) system

BACKGROUND

Annually, 2.6 million stillbirths occur around the world, with approximately 98% occurring in low- and middle-income countries. The stillbirth rates in these countries are 10 times higher than the rates in high-income countries.

METHODS

An electronic stillbirths and neonatal deaths surveillance system (JSANDS) was established in five large hospitals located in three of the largest cities in Jordan in August 2019. JSANDS was developed as a secure on-line data entry system to collect, organize, analyze, and disseminate data on stillbirths, neonatal deaths, and their contributing conditions. Data on births, stillbirths and their contributing conditions, and other demographic and clinical characteristics in the period between August 2019 - January 2020 were extracted and analyzed.

RESULTS

A total of 10,328 births were registered during the reporting period. Of the total births, 102 were born dead (88 antepartum stillbirths and 14 intrapartum stillbirths), with a rate of 9.9 per 1000 total births. The main contributing fetal conditions of antepartum stillbirths were antepartum death of unspecified cause (33.7%), acute antepartum event (hypoxia) (33.7%), congenital malformations and chromosomal abnormalities (13.3%), and disorders related to the length of gestation and fetal growth (10.8%). The main contributing maternal conditions of antepartum stillbirths included complications of the placental cord and membranes (48.7%), maternal complications of pregnancy (23.1%), and maternal medical and surgical conditions (23.1%). Contributing fetal conditions of intrapartum stillbirths included congenital malformations, deformations and chromosomal abnormalities, other specified intrapartum disorders, and intrapartum death of unspecified cause (33.3% each). Contributing maternal conditions of intrapartum stillbirths included complications of the placental cord and membranes. In the multivariate analysis, small for gestational age (SGA) pregnancies were associated with a significant 3-fold increased risk of stillbirth compared to appropriate for gestational age (AGA) pregnancies.

CONCLUSIONS

Although the rate of stillbirth is lower than that in other countries in the region, there is an opportunity to prevent such deaths. While the majority of stillbirths occurred during the antepartum period, care should be taken for the early identification of high-risk pregnancies, including the early detection of SGA pregnancies, and ensuring adequate antenatal obstetric interventions.

Factors associated with stillbirth in selected countries of South Asia: A systematic review of observational studies

BACKGROUND

Despite having the high rate of stillbirth in most of the countries of South Asia, there is a lack of synthesized evidence based on factors associated with stillbirth. This study systematically synthesizes the evidence on factors associated with stillbirth in the four selected countries of South Asia.

METHODS

This review was conducted using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Studies that examined factors associated with stillbirth in South Asia were searched using five major electronic search databases including MEDLINE, CINAHL, Embase, PsycINFO, and Scopus, published between January 2000 and December 2019. In the meta-analysis, significant heterogeneity was detected among studies (I2 >50%), and hence a random effect model was used.

RESULTS

A total of 20 studies met the inclusion criteria. The pooled rate of stillbirth from the studies in Bangladesh, India, Nepal, and Pakistan was 25.15 per 1000 births. Pregnancy complications, maternal health conditions, fetal complications, lack of antenatal care, and lower Socio Economic Status (SES) were the most common factors associated with stillbirth in countries of South Asia.

CONCLUSION

This study confirmed that stillbirth in selected countries of South Asia remains high. To reduce stillbirth, a greater focus needs to be on timely management of preterm labor, maternal hypertension, and provision of financial support for quality antenatal and delivery care. The interventions should be targeted for women living in remote areas, who are less educated and those with low SES.

Stillbirth in Iran and associated factors (2014-2016): A population-based study

Background: Under Every Newborn Action Plan (ENAP), stillbirth rate in every country should be reduced by 12 or fewer per 1000 total births by 2030. The aims of this study were to determine stillbirth rate at national and subnational levels and to investigate its associated risk factors in Iran.

Methods: Using all data from Iranian Maternal and Neonatal Network (IMaN), we calculated stillbirth rate of Iran from 2014-2016. This network registers information of almost all births across the country. The logistic regression was used to estimate the adjusted odds ratio (aOR) with 95% confidence intervals (CIs) for stillbirth.

Results: In 2014, still birth rate was 7.40 per 1000 births. In 2015 and 2016, stillbirth rates were 7.22 per 1000 births and 7.63 per 1000 births, respectively. The most important related factors of stillbirth were preterm birth (aOR= 62.53, 95% CI; 60.77-64.34), sexual ambiguity (aOR= 14.51, 95% CI; 12.76-16.50), and post term birth (aOR= 3.31, 95% CI; 2.66-4.13).

Conclusion: Under Every Newborn Action Plan (ENAP), stillbirth rate in every country should be reduced by 12 or fewer per 1000 total births by 2030. Iran has achieved stillbirth target of ENAP at national level. It is important for the health care system to establish and improve specific and focused policies, interventions, and programs for achieving this target even in the most deprived areas.

Sex- and growth-specific characteristics of small for gestational age infants: a prospective cohort study

Background

Asymmetric fetal growth and male sex are both associated with adverse neonatal outcome. However, less is known about the influence of asymmetric growth and fetal sex within SGA neonates, a group of infants already at increased risk for adverse neonatal outcomes. The aim of the present study was to provide insight into variance in risk factors for SGA in a fetal sex- and growth symmetry-specific way.

Methods

For this prospective, multicenter cohort study, data from the Screening for Pregnancy Endpoints (SCOPE) study were used with 5628 nulliparous participants, of which 633 (11.3%) pregnancies were complicated with SGA and 3376 (60.0%) women had uncomplicated pregnancies. Association between risk factors for SGA, SGA subgroups, and uncomplicated pregnancies were assessed with multivariable analyses.

Results

Prevalence of asymmetric growth varied from 45.8% of SGA infants to 5.5% of infants with a customized birthweight > 90th percentile (p < 0.001). Significantly more SGA males had asymmetric growth compared to SGA female infants (51.2% vs 40.4%, p = 0.009). Maternal pre-pregnancy diet and BMI < 20 and ≥ 30 were significantly associated with symmetric SGA but not with asymmetric SGA. Asymmetric SGA infants had not only lower customized birthweight percentile (4.4 (SD 2.8) vs 5.0 (SD 3.0), p < 0.001), but also lower rates of stillbirth (p = 0.041) and less often Apgar scores < 7 (p = 0.060).

Conclusions

Among SGA infants, low customized birthweight percentiles and male sex are associated with asymmetric growth. Only symmetric SGA is significantly associated with maternal risk factors in early pregnancy. There is a substantial variance in risk factors and neonatal outcomes for SGA based on growth symmetry, implying a different pathogenesis.

Trial registration

ACTRN12607000551493

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.

Understanding pathways leading to stillbirth: The role of care-seeking and care received during pregnancy and childbirth in Kabul province, Afghanistan

BACKGROUND

The underlying pathways leading to stillbirth in low- and middle-income countries are not well understood. Context-specific understanding of how and why stillbirths occur is needed to prioritise interventions and identify barriers to their effective implementation and uptake.

AIM

To explore the contribution of contextual, individual, household-level and health system factors to stillbirth in Afghanistan.

METHODS

Using a qualitative approach, we conducted semi-structured in-depth interviews with women and men that experienced stillbirth, female elders, community health workers, healthcare providers, and government officials in Kabul province, Afghanistan between October-November 2017. We used thematic analysis to identify contributing factors and developed a conceptual map describing possible pathways to stillbirth.

FINDINGS

We found that low utilisation and access to healthcare was a key contributing factor, as were unmanaged conditions in pregnancy that increased women's risk of complications and stillbirth. Sociocultural factors related to the treatment of women and perceptions about medical interventions deprived women of interventions that could potentially prevent stillbirth. The quality of care from public and private providers during pregnancy and childbirth was a recurring concern exacerbated by health system constraints that led to unnecessary delays; while environmental factors linked to the ongoing conflict were also perceived to contribute to stillbirth. These pathways were underscored by social, cultural, economic factors and individual perceptions that contributed to the three-delays.

DISCUSSION

Efforts are needed at the community-level to facilitate care-seeking and raise awareness of stillbirth risk factors and the facility-level to strengthen antenatal and childbirth care quality, ensure culturally appropriate and respectful care, and reduce treatment delays.

Exploring women and traditional birth attendants' perceptions and experiences of stillbirths in district Thatta, Sindh, Pakistan: a qualitative study

Background

Pakistan reports the highest stillbirth rate in the world at 43 per thousand births with more than three-quarters occurring in rural areas. The Global Network for Women’s and Children’s Health maintains a Maternal and Newborn Health Registry (MNHR) in 14 study clusters of district Thatta, Sindh Pakistan. For the last 10 years, the MNHR has recorded a high stillbirths rate with a slow decline. This exploratory study was designed to understand the perspectives of women and traditional birth attendants regarding the high occurrence of stillbirth in Thatta district.

Methods

We used an exploratory qualitative study design by conducting in-depth interviews (IDIs) and focus group discussions (FGDs) using semi-structured interview guide with rural women (FGDs = 4; n = 29) and traditional birth attendants (FGDs = 4; n = 14) who were permanent residents of Thatta. In addition, in-depth interviews were conducted with women who had experienced a stillbirth (IDIs = 4). This study presents perceptions and experiences of women and TBAs regarding high rate of stillbirth in Thatta district, Karachi.

Results

Women showed reluctance to receive skilled/ standard care when in need due to apprehensions towards operative delivery, poor attitude of skilled health care providers, and poor quality of care as service delivery factors. High cost of care, far distance to facility, lack of transport and need of an escort from the family or village to visit a health facility were additional important factors for not seeking care resulting in stillbirth. The easy availability of unskilled provider in the form of traditional birth attendant is then preferred over a skilled health care provider. TBAs shared their husband or family members restrict them to visit or consult a doctor during pregnancy. According to TBAs after delivering a macerated fetus, women are given herbs to remove infection from woman‘s body and uterus. Further women are advised to conceive soon so that they get rid of infections.

Conclusion

Women of this rural community carry lots of apprehension against skilled medical care and as a result follow traditional practices. Conscious efforts are required to increase the awareness of women to develop positive health seeking behavior during pregnancy, delivery and the post-partum period. Alongside, provision of respectful maternity care needs to be emphasized especially at public health facilities.

Single-lead noninvasive fetal ECG extraction by means of combining clustering and principal components analysis

Early detection of potential hazards in the fetal physiological state during pregnancy and childbirth is very important. Noninvasive fetal electrocardiogram (FECG) can be extracted from the maternal abdominal signal. However, due to the interference of maternal electrocardiogram and other noises, the task of extraction is challenging. This paper introduces a novel single-lead noninvasive fetal electrocardiogram extraction method based on the technique of clustering and PCA. The method is divided into four steps: (1) pre-preprocessing; (2) fetal QRS complexes and maternal QRS complexes detection based on k-means clustering algorithm with the feature of max-min pairs; (3) FQRS correction step is to improve the performance of step two; (4) template subtraction based on PCA is introduced to extract FECG waveform. To verify the performance of the proposed algorithm, two clinical open-access databases are used to check the performance of FQRS detection. As a result, the method proposed shows the average PPV of 95.35%, Se of 96.23%, and F1-measure of 95.78%. Furthermore, the robustness test is carried out on an artificial database which proves that the algorithm has certain robustness in various noise environments. Therefore, this method is feasible and reliable to detect fetal heart rate and extract FECG. Graphical abstract Early detection of potential hazards in the fetal physiological state during pregnancy and childbirth is very important. Noninvasive fetal electrocardiogram (FECG) can be extracted from maternal abdominal signal. However, due to the interference of maternal electrocardiogram and other noises, the task of extraction is challenging. This paper introduces a novel single-lead noninvasive fetal electrocardiogram extraction method based on the technique of clustering and PCA. The method is divided into four steps: (1) pre-preprocessing; (2) fetal QRS complexes and maternal QRS complexes detection based on k-means clustering algorithm with the feature of max-min pairs; (3) FQRS correction step is to improve the performance of step two; (4) template subtraction based on PCA is introduced to extract FECG waveform. To verify the performance of algorithm, two clinical open-access databases are used to check the performance of FQRS detection. As a result, the method proposed shows the average PPV of 95.35%, Se of 96.23%, and F1-measure of 95.78%. Furthermore, the robustness test is carried out on an artificial database which proves that the algorithm has certain robustness in various noise environments. Therefore, this method is feasible and reliable to detect fetal heart rate and extract FECG.

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.

Fetal electrocardiography extraction with residual convolutional encoder-decoder networks

In the context of fetal monitoring, non-invasive fetal electrocardiography is an alternative approach to the traditional Doppler ultrasound technique. However, separating the fetal electrocardiography (FECG) component from the abdominal electrocardiography (AECG) remains a challenging task. This is mainly due to the interference from maternal electrocardiography, which has larger amplitude and overlaps with the FECG in both temporal and frequency domains. The main objective is to present a novel approach to FECG extraction by using a deep learning strategy from single-channel AECG recording. A residual convolutional encoder-decoder network (RCED-Net) is developed for this task of FECG extraction. The single-channel AECG recording is the input to the RCED-Net. And the RCED-Net extracts the feature of AECG and directly outputs the estimate of FECG component in the AECG recording. The AECG recordings from two different databases are collected to illustrate the efficiency of the proposed method. And the achieved results show that the proposed technique exhibits the best performance when compared to the existing methods in the literature. This work is a proof of concept that the proposed method could effectively extract the FECG component from AECG recordings. The focus on single-channel FECG extraction technique contributes to the commercial applications for long-term fetal monitoring.

Systematic identification of facility-based stillbirths and neonatal deaths through the piloted use of an adapted RAPID tool in Liberia and Nepal

Maternal, fetal, and neonatal health outcomes are interdependent. Designing public health strategies that link fetal and neonatal outcomes with maternal outcomes is necessary in order to successfully reduce perinatal and neonatal mortality, particularly in low- and middle- income countries. However, to date, there has been no standardized method for documenting, reporting, and reviewing facility-based stillbirths and neonatal deaths that links to maternal health outcomes would enable a more comprehensive understanding of the burden and determinants of poor fetal and neonatal outcomes. We developed and pilot-tested an adapted RAPID tool, Perinatal-Neonatal Rapid Ascertainment Process for Institutional Deaths (PN RAPID), to systematically identify and quantify facility-based stillbirths and neonatal deaths and link them to maternal health factors in two countries: Liberia and Nepal. This study found an absence of stillbirth timing documented in records, a high proportion of neonatal deaths occurring within the first 24 hours, and an absence of documentation of pregnancy-related and maternal factors that might be associated with fetal and neonatal outcomes. The use of an adapted RAPID methodology and tools was limited by these data gaps, highlighting the need for concurrent strengthening of death documentation through training and standardized record templates.

Distinct mortality patterns at 0-2 days versus the remaining neonatal period: results from population-based assessment in the Indian state of Bihar

BACKGROUND

The objectives of this study were to understand the differences in mortality rate, risk factors for mortality, and cause of death distribution in three neonatal age sub-groups (0-2, 3-7, and 8-27 days) and assess the change in mortality rate with previous assessments to inform programmatic decision-making in the Indian state of Bihar, a large state with a high burden of newborn deaths.

METHODS

Detailed interviews were conducted in a representative sample of 23,602 live births between January and December 2016 (96.2% participation) in Bihar state. We estimated the neonatal mortality rate (NMR) for the three age sub-groups and explored the association of these deaths with a variety of risk factors using a hierarchical logistic regression model approach. Verbal autopsies were conducted using the PHMRC questionnaire and the cause of death assigned using the SmartVA automated algorithm. Change in NMR from 2011 to 2016 was estimated by comparing it with a previous assessment.

RESULTS

The NMR 0-2-day, 3-7-day, and 8-27-day mortality estimates in 2016 were 24.7 (95% CI 21.8-28.0), 13.2 (11.1 to 15.7), 5.8 (4.4 to 7.5), and 5.8 (4.5 to 7.5) per 1000 live births, respectively. A statistically significant reduction of 23.3% (95% CI 9.2% to 37.3) was seen in NMR from 2011 to 2016, driven by a reduction of 35.3% (95% CI 18.4% to 52.2) in 0-2-day mortality. In the final regression model, the highest odds for mortality in 0-2 days were related to the gestation period of ≤ 8 months (OR 16.5, 95% CI 11.9-22.9) followed by obstetric complications, no antiseptic cord care, and delivery at a private health facility or home. The 3-7- and 8-27-day mortality was driven by illness in the neonatal period (OR 10.33, 95% CI 6.31-16.90, and OR 4.88, 95% CI 3.13-7.61, respectively) and pregnancy with multiple foetuses (OR 5.15, 95% CI 2.39-11.10, and OR 11.77, 95% CI 6.43-21.53, respectively). Birth asphyxia (61.1%) and preterm delivery (22.1%) accounted for most of 0-2-day deaths; pneumonia (34.5%), preterm delivery (33.7%), and meningitis/sepsis (20.1%) accounted for the majority of 3-7-day deaths; meningitis/sepsis (30.6%), pneumonia (29.1%), and preterm delivery (26.2%) were the leading causes of death at 8-27 days.

CONCLUSIONS

To our knowledge, this is the first study to report a detailed neonatal epidemiology by age sub-groups for a major Indian state, which has highlighted the distinctly different mortality rate, risk factors, and causes of death at 0-2 days versus the rest of the neonatal period. Monitoring mortality at 0-2 and 3-7 days separately in the traditional early neonatal period of 0-7 days would enable more effective programming to reduce neonatal mortality.

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.

Deferred and referred deliveries contribute to stillbirths in the Indian state of Bihar: results from a population-based survey of all births

BACKGROUND

The India Newborn Action Plan (INAP) aims for < 10 stillbirths per 1000 births by 2030. A population-based understanding of risk factors for stillbirths compared with live births that could assist with reduction of stillbirths is not readily available for the Indian population.

METHODS

Detailed interviews were conducted in a representative sample of all births between January and December 2016 from 182,486 households (96.2% participation) in 1657 clusters in the Indian state of Bihar. A stillbirth was defined as foetal death with gestation period of ≥ 7 months wherein the foetus did not show any sign of life. The association of stillbirth was investigated with a variety of risk factors among all births using a hierarchical logistic regression model approach.

RESULTS

A total of 23,940 births including 338 stillbirths were identified giving the state stillbirth rate (SBR) of 15.4 (95% CI 13.2-17.9) per 1000 births, with no difference in SBR by sex. Antepartum and intrapartum SBR was 5.6 (95% CI 4.3-7.2) and 4.5 (95% CI 3.3-6.1) per 1000 births, respectively. Detailed interview was available for 20,152 (84.2% participation) births including 275 stillbirths (81.4% participation). In the final regression model, significantly higher odds of stillbirth were documented for deliveries with gestation period of ≤ 8 months (OR 11.36, 95% CI 8.13-15.88), for first born (OR 5.79, 95% CI 4.06-8.26), deferred deliveries wherein a woman was sent back home and asked to come later for delivery by a health provider (OR 5.51, 95% CI 2.81-10.78), and in those with forceful push/pull during the delivery by the health provider (OR 4.85, 95% CI 3.39-6.95). The other significant risk factors were maternal age ≥ 30 years (OR 3.20, 95% CI 1.52-6.74), pregnancies with multiple foetuses (OR 2.82, 95% CI 1.49-5.33), breech presentation of the baby (OR 2.70, 95% CI 1.75-4.18), and births in private facilities (OR 1.75, 95% CI 1.19-2.56) and home (OR 2.60, 95% CI 1.87-3.62). Varied risk factors were associated with antepartum and intrapartum stillbirths. Birth weight was available only for 40 (14.5%) stillborns. Among the facility deliveries, the women who were referred from one facility to another for delivery had significantly high odds of stillbirth (OR 3.32, 95% CI 2.03-5.43).

CONCLUSIONS

We found an increased risk of stillbirths in deferred and referred deliveries in addition to demographic and clinical risk factors for antepartum and intrapartum stillbirths, highlighting aspects of health care that need attention in addition to improving skills of health providers to reduce stillbirths. The INAP could utilise these findings to further strengthen its approach to meet the stillbirth reduction target by 2030.

Understanding country-specific determinants of stillbirth using household surveys: The case of Afghanistan

BACKGROUND

Stillbirth rates in Afghanistan have declined little in the past decade with no data available on key risk factors. Health care utilisation and maternal complications are important factors influencing pregnancy outcomes but rarely captured for stillbirth in national surveys from low- and middle-income countries. The 2010 Afghanistan Mortality Survey (AMS) is one of few surveys with this information.

METHODS

We used data from the 2010 AMS that included a full pregnancy history and verbal autopsy. Our sample included the most recent live birth or stillbirth of 13 834 women aged 12-49 years in the three years preceding the survey. Multivariable Poisson regression was used to identify sociodemographic, maternal, and health care utilisation risk factors for stillbirth.

RESULTS

The risk of stillbirth was increased among women in the Central Highlands (aRR: 3.01, 95% CI 1.35, 6.70) and of Nuristani ethnicity (aRR: 9.15, 95% CI 2.95, 28.74). Women who did not receive antenatal care had three times increased risk of stillbirth (aRR: 3.03, 95% CI 1.73, 5.30), while high-quality antenatal care was important for reducing the risk of intrapartum stillbirth. Bleeding, infection, headache, and reduced fetal movements were antenatal complications strongly associated with stillbirth. Reduced fetal movements in the delivery period increased stillbirth risk by almost seven (aRR: 6.82, 95% CI 4.20, 11.10). Facility births had a higher risk of stillbirths overall (aRR: 1.55, 95% CI 1.12, 2.16), but not for intrapartum stillbirths.

CONCLUSIONS

Targeted interventions are needed to improve access and utilisation of services for high-risk groups. Early detection of complications through improved quality of antenatal and obstetric care is imperative. We demonstrate the potential of household surveys to provide country-specific evidence on stillbirth risk factors for LMICs where data are lacking.

Identifying potential uses of crowdsourcing in global health, conflict, and humanitarian settings: an adapted CHNRI (Child Health and Nutrition Initiative) exercise

Background

Crowdsourcing, outsourcing problems and tasks to a crowd, has grown exponentially since the term was coined a decade ago. Being a rapid and inexpensive approach, it is particularly amenable to addressing problems in global health, conflict and humanitarian settings, but its potential has not been systematically assessed. We employed the Child Health and Nutrition Research Initiative's (CHNRI) method to generate a ranked list of potential uses of crowdsourcing in global health and conflict.

Process

94 experts in global health and crowdsourcing submitted their ideas, and 239 ideas were scored. Each expert scored ideas against three of seven criteria, which were tailored specifically for the exercise. A relative ranking was calculated, along with an Average Expert Agreement (AEA).

Findings

On a scale from 0-100, the scores assigned to proposed ideas ranged from 80.39 to 42.01. Most ideas were related to problem solving (n = 112) or data generation (n = 91). Using health care workers to share information about disease outbreaks to ensure global response had the highest score and agreement. Within the top 15, four additional ideas related to containing communicable diseases, two ideas related to using crowdsourcing for vital registration and two to improve maternal and child health. The top conflict ideas related to epidemic responses and various aspects of disease spread. Wisdom of the crowds and machine learning scored low despite being promising in literature.

Interpretations

Experts were invited to generate ideas during the Ebola crisis and to score during reports of Zika, which may have affected the scoring. However, crowdsourcing's rapid, inexpensive characteristics make it suitable for addressing epidemics. Given that many ideas reflected Sustainable Development Goals (SDGs), crowdsourcing may be an innovative solution to achieving some of the SDGs.

Disentangling the contributions of maternal and fetal factors to estimate stillbirth risks for intrapartum adverse events in Tanzania and Uganda

OBJECTIVE

To estimate the stillbirth risk associated with intrapartum adverse events, controlling for fetal and maternal factors.

METHODS

The present study was an analysis of cross-sectional patient-record and facility-file data from women with viable fetuses who experienced obstetric adverse events at 23 hospitals and 38 health centers in Tanzania (between December 2015 and October 2016), and 22 hospitals, 16 level-4 health centers, and five level-3 health centers in Uganda (between May 2016 and September 2017). Adverse events were categorized in three severity groups (postpartum, intrapartum non-near-miss, and intrapartum near-miss) to calculate stillbirth rates and adjusted prevalence ratios.

RESULTS

Data from 3816 women in Tanzania and 8305 in Uganda were included. Compared with postpartum adverse events, intrapartum near-miss was associated with a 3.73- and 4.55-fold higher prevalence of stillbirth in Uganda and Tanzania, respectively. Most women who experienced near-miss had organ dysfunction on arrival or developed it soon after. The risk of stillbirth was higher among preterm deliveries compared with term deliveries, and was 42% and 59% lower in Tanzania and Uganda, respectively, for cesarean deliveries compared with vaginal deliveries after intrapartum non-near-miss adverse events.

CONCLUSION

Stillbirth risk increased with severity of complications and was higher among premature deliveries. Survival was higher for cesarean deliveries in intrapartum non-near-miss complications, identifying the opportunity to prevent deterioration by timely actions.

Stillbirth in the African Great Lakes region: A pooled analysis of Demographic and Health Surveys

Background

The aim of this study was to estimate the rate and predisposing factors associated with stillbirth in the African Great Lakes region (Burundi, Congo Democratic Republic, Kenya, Rwanda, Tanzania and Uganda).

Methods and findings

Cross-sectional data from the most recent Demographic and Health Surveys (DHS) of countries in the African Great Lakes region were used in this study. DHS from Congo Democratic Republic was not included in the analyses because data was not collected for stillbirth in the country survey. A pooled sample of 57046 pregnancies of 7+ months’ duration and 1002 stillbirths were included in the final analysis. The analyses were restricted to stillbirths reported in the 5 years preceding the surveys. Stillbirth was defined as foetal death in the third trimester (≥ 28 weeks’ gestation). Multilevel logistic regression analyses that adjusted for cluster and survey weights were used to determine the factors associated with stillbirth in the Africa Great Lakes region. Health service variables and maternal medical condition variables were not included in the analysis because DHS do not collect data on these variables for pregnancies that did not result in a live birth. Burundi had the highest stillbirth rate per 1000 births [23% (95% CI: 20, 25)] within the region. Factors associated with stillbirth across the region were: no schooling [1.85 (95%Cl: 1.44, 2.38)] and primary education [1.64 (1.32, 2.05)], advanced maternal age [2.39 (95% CI: 1.59, 3.59)], smoking [1.99 (95% CI: 1.19, 3.32)] and drinking water from unimproved sources [1.18 (95% CI: 1.01, 1.37)].

Conclusion

To achieve Every Newborn Action Plan (ENAP) stillbirth target of 12 per 1000 births or less by 2030, policy interventions to prevent stillbirth should focus on promoting community-based socio-educational programmes which encourages a healthy lifestyle especially among uneducated women in the advanced age spectrum.

Stillbirth rate and causes in a low-resource setting, Mpilo Central Hospital, Bulawayo, Zimbabwe

A global concern is to end preventable stillbirths by the year 2030. The objective of this study was to document the stillbirth rate and causes of stillbirths in a low-resource setting. This was a retrospective descriptive study carried out at Mpilo Central Hospital, a tertiary teaching referral government hospital in Bulawayo, Zimbabwe during the period January to December 2016. There were 8801 live births and 268 stillbirths (rate: 30.5/1000). The majority(81.3%) were macerated. Pre-term labour, pre-eclampsia, eclampsia and abruptio placenta accounted for 51.1%. In 29.9%, the cause could not be identified. A high proportion of macerated stillbirths were unexplained; hence this calls for a renewed focus on community-based approaches to reduce delays in seeking care. Investment in robust diagnostic means and further training of healthcare workers to improve case definition are both urgently required.

Tracking facility-based perinatal deaths in Tanzania: Results from an indicator validation assessment

BACKGROUND

Globally, an estimated 2.7 million babies die in the neonatal period annually, and of these, about 0.7 million die from intrapartum-related events. In Tanzania 51,000 newborn deaths and 43,000 stillbirths occur every year. Approximately two-thirds of these deaths could be potentially prevented with improvements in intrapartum and neonatal care. Routine measurement of fetal intrapartum deaths and newborn deaths that occur in health facilities can help to evaluate efforts to improve the quality of intrapartum care to save lives. However, few examples exist of indicators on perinatal mortality in the facility setting that are readily available through health management information systems (HMIS).

METHODS

From November 2016 to April 2017, health providers at 10 government health facilities in Kagera region, Tanzania, underwent refresher training on perinatal death classification and training on the use of handheld Doppler devices to assess fetal heart rate upon admission to maternity services. Doppler devices were provided to maternity services at the study facilities. We assessed the validity of an indicator to measure facility-based pre-discharge perinatal mortality by comparing perinatal outcomes extracted from the HMIS maternity registers to a gold standard perinatal death audit.

RESULTS

Sensitivity and specificity of the HMIS neonatal outcomes to predict gold standard audit outcomes were both over 98% based on analysis of 128 HMIS-gold standard audit pairs. After this validation, we calculated facility perinatal mortality indicator from HMIS data using fresh stillbirths and pre-discharge newborn death as the numerator and women admitted in labor with positive fetal heart tones as the denominator. Further emphasizing the validity of the indicator, FPM values aligned with expected mortality by facility level, with lowest rates in health centers (range 0.3%- 0.5%), compared to district hospitals (1.5%- 2.9%) and the regional hospital (4.2%).

CONCLUSION

This facility perinatal mortality indicator provides an important health outcome measure that facilities can use to monitor levels of perinatal deaths occurring in the facility and evaluate impact of quality of care improvement activities.