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

Facility-based stillbirth review processes used in different countries across the world: a systematic review

Background

Facility-based stillbirth review provides opportunities to estimate incidence, evaluate causes and risk factors for stillbirths, and identify any issues related to the quality of pregnancy and childbirth care which require improvement. Our aim was to systematically review all types and methods of facility-based stillbirth review processes used in different countries across the world, to examine how stillbirth reviews in facility settings are being conducted worldwide and to identify the outcomes of implementing the reviews. Moreover, to identify facilitators and barriers influencing the implementation of the identified facility-based stillbirth reviews processes by conducting subgroup analyses.

Methods

A systematic review of published literature was conducted by searching MEDLINE (OvidSP) [1946-present], EMBASE (OvidSP) [1974-present], WHO Global Index Medicus (globalindexmedicus.net), Global Health (OvidSP) [1973-2022 Week 8] and CINAHL (EBSCOHost) [1982-present] from their inception until 11 January, 2023. For unpublished or grey literature, the WHO databases, Google Scholar and ProQuest Dissertations & Theses Global were searched, as well as hand searching the reference lists of included studies. MESH terms encompassing "∗Clinical Audit", "∗Perinatal Mortality", "Pregnancy Complications", and "Stillbirth" were used with Boolean operators. Studies that used a facility-based review process or any approach to evaluate care prior to stillbirth, and explained the methods used were included. Reviews and editorials were excluded. Three authors (YYB, UGA, and DBT) independently screened and extracted data, and assessed the risk of bias using an adapted JBI's Checklist for Case Series. A logic model was used to inform the narrative synthesis. The review protocol was registered with PROSPERO, CRD42022304239.

Findings

A total of 68 studies from 17 high-income (HICs) and 22 low-and-middle-income countries (LMICs) met the inclusion criteria from a total of 7258 identified records. These were stillbirth reviews conducted at different levels: district, state, national, and international. Three types were identified: audit, review, and confidential enquiry, but not all desired components were included in most processes, which led to a mismatch between the description of the type and the actual method used. Routine data from hospital records was the most common data source for identifying stillbirths, and case assessment was based on stillbirth definition in 48 out of 68 studies. Hospital notes were the most common source of information about care received and causes/risk factors for stillbirth. Short-term and medium-term outcomes were reported in 14 studies, but impact of the review process on reducing stillbirth, which is more difficult to establish, was not reported in any study. Facilitators and barriers in implementing a successful stillbirth review process identified from 14 studies focused on three main themes: resources, expertise, and commitment.

Interpretation

This systematic review's findings identified that there is a need for clear guidelines on how to measure the impact of implementation of changes based on outputs of stillbirth reviews and methods to enable effective dissemination of learning points in the future and promoting them through training platforms. In addition, there is a need to develop and adopt a universal definition of stillbirth to facilitate meaningful comparison of stillbirth rates between regions. The key limitation of this review is that while using a logic model for narrative synthesis was deemed most appropriate for this study, sequence of implementing a stillbirth review in the real world is not linear, and assumptions are often not met. Therefore, the logic model proposed in this study should be interpreted with flexibility when designing a stillbirth review process. The generated learnings from the stillbirth review processes inform the action plans and allow facilities to consider where the changes should happen to improve the quality of care in the facilities, enabling positive short-term and medium-term outcomes.

Funding

Kellogg College, University of Oxford, Clarendon Fund, University of Oxford, Nuffield Department of Population Health, University of Oxford and Medical Research Council (MRC).

Determinants of stillbirth among reviewed perinatal deaths in Ethiopia

BACKGROUND

The global burden of stillbirth has declined over time. However, the problem is still prominent in South Asian and Sub-Saharan African countries. Ethiopia is one of the top stillbirth-reporting countries worldwide. Despite several measures taken to reduce the burden of stillbirth; the pace of decline was not as good as the post-neonatal death. Thus, this study is aimed at identifying potential factors related to stillbirth in Ethiopia based on nationally reviewed perinatal deaths.

METHOD

The national perinatal death surveillance data were used for this study. A total of 3,814 reviewed perinatal death were included in the study. Two model families,namely generalized estimating equation, and alternating logistic regression models from marginal model family were employed to investigate the risk factors of stillbirth. The alternating logistic regression model was selected as the best fit for the final analysis.

RESULT

Among reviewed perinatal deaths nearly forty percent (37.4%) were stillbirths. The findings from the multivariate analysis demonstrated that the place of birth (in transit and at home), cause of death (infection, and congenital and chromosomal abnormalities), maternal health condition (women with complications of pregnancy, placenta, and cord), delay one (delay in deciding to seek care) and delay three (delay in receiving adequate care) were associated with an increased risk of having a stillbirth. On the other hand, maternal education (women with primary and above education level) and the type of health facility (women who were treated in secondary and tertiary health care) were associated with a decreased risk of having a stillbirth.

CONCLUSION

The study identified that both individual (place of delivery, cause of death, maternal health condition, maternal education, and delay one) and facility level (type of health facility and delay three) factors contributed to stillbirth outcome. Therefore, policies that are aimed at encouraging institutional delivery, improving health seeking behavior, and strengthening facility-level readiness should be devised to reduce the high burden of stillbirth in Ethiopia.