Stillbirth and neonatal mortality in a subsequent pregnancy following stillbirth: a population-based cohort study

Socioeconomic inequalities in adverse pregnancy outcomes in India: 2004-2019

Although India has made substantial improvements in public health, it accounted for one-fifth of global maternal and neonatal deaths in 2015. Stillbirth, abortion, and miscarriage contribute to maternal and infant morbidity and mortality. There are known socioeconomic inequalities in adverse pregnancy outcomes. This study estimated changes in socioeconomic inequalities in rates of stillbirth, abortion, and miscarriage in India across 15 years. We combined data from three nationally representative health surveys. Absolute inequalities were estimated using the slope index of inequality and risk differences, and relative inequalities were estimated using the relative index of inequalities and risk ratios. We used household wealth, maternal education, and Scheduled Caste and Scheduled Tribe membership as socioeconomic indicators. We observed persistent socioeconomic inequalities in abortion and stillbirth from rates of 2004-2019. Women at the top of the wealth distribution reported between 2 and 5 fewer stillbirths per 1,000 pregnancies over the study time period compared to women at the bottom of the wealth distribution. Women who completed primary school, and those at the top of the household wealth distribution, had, over the study period, 5 and 20 additional abortions per 1,000 pregnancies respectively compared to women who did not complete primary school and those at the bottom of the wealth distribution. Women belonging to a Scheduled Caste or Scheduled Tribe had 5 fewer abortions per 1,000 pregnancies compared to other women, although these inequalities diminished by the end of the study period. There was less consistent evidence for socioeconomic inequalities in miscarriage, which increased for all groups over the study period. Despite targeted investments by the Government of India to improve access to health services for socioeconomically disadvantaged groups, disparities in pregnancy outcomes persist.

Association of previous stillbirth with subsequent perinatal outcomes: a systematic review and meta-analysis of cohort studies

OBJECTIVE

We conducted a systematic review and meta-analysis to examine the relationship between stillbirth and various perinatal outcomes in subsequent pregnancy.

DATA SOURCES

PubMed, the Cochrane Library, Embase, Web of Science, and CNKI databases were searched up to July 2023.

STUDY ELIGIBILITY CRITERIA

Cohort studies that reported the association between stillbirth and perinatal outcomes in subsequent pregnancies were included.

METHODS

We conducted this systematic review and meta-analysis in accordance with the PRISMA guidelines. Statistical analysis was performed using R and Stata software. We used random-effects models to pool each outcome of interest. We performed a meta-regression analysis to explore the potential heterogeneity. The certainty (quality) of evidence assessment was performed using the GRADE approach.

RESULTS

Nineteen cohort studies were included, involving 4,855,153 participants. From these studies, we identified 28,322 individuals with previous stillbirths who met the eligibility criteria. After adjusting for confounders, evidence of low to moderate certainty indicated that compared with women with previous live births, women with previous stillbirths had higher risks of recurrent stillbirth (odds ratio, 2.68; 95% confidence interval, 2.01-3.56), preterm birth (odds ratio, 3.15; 95% confidence interval, 2.07-4.80), neonatal death (odds ratio, 4.24; 95% confidence interval, 2.65-6.79), small for gestational age/intrauterine growth restriction (odds ratio, 1.3; 95% confidence interval, 1.0-1.8), low birthweight (odds ratio, 3.32; 95% confidence interval, 1.46-7.52), placental abruption (odds ratio, 3.01; 95% confidence interval, 1.01-8.98), instrumental delivery (odds ratio, 2.29; 95% confidence interval, 1.68-3.11), labor induction (odds ratio, 4.09; 95% confidence interval, 1.88-8.88), cesarean delivery (odds ratio, 2.38; 95% confidence interval, 1.20-4.73), elective cesarean delivery (odds ratio, 2.42; 95% confidence interval, 1.82-3.23), and emergency cesarean delivery (odds ratio, 2.35; 95% confidence interval, 1.81-3.06) in subsequent pregnancies, but had a lower rate of spontaneous labor (odds ratio, 0.22; 95% confidence interval, 0.13-0.36). However, there was no association between previous stillbirth and preeclampsia (odds ratio, 1.72; 95% confidence interval, 0.63-4.70) in subsequent pregnancies.

CONCLUSION

Our systematic review and meta-analysis provide a more comprehensive understanding of adverse pregnancy outcomes associated with previous stillbirth. These findings could be used to inform counseling for couples who are considering pregnancy after a previous stillbirth.

Risk of stillbirth and adverse pregnancy outcomes in a third pregnancy when an earlier pregnancy has ended in stillbirth

INTRODUCTION

Our study evaluated how a history of stillbirth in either of the first two pregnancies affects the risk of having a stillbirth or other adverse pregnancy outcomes in the third subsequent pregnancy.

MATERIAL AND METHODS

We used the Swedish Medical Birth Register to define a population-based cohort of women who had at least three singleton births from 1973 to 2012. The exposure of interest was a history of stillbirth in either of the first two pregnancies. The primary outcome was subsequent stillbirth in the third pregnancy. Secondary outcomes included: preterm birth, preeclampsia, placental abruption and small-for-gestational-age infant. Adjusted logistic regression was performed including maternal age, body mass index, smoking, diabetes and hypertension. A sensitivity analysis was performed excluding stillbirths associated with congenital anomalies, pregestational and gestational diabetes, hypertension and preterm stillbirths.

RESULTS

The study contained data on 1 316 175 births, including 8911 stillbirths. Compared with women who had two live births, the highest odds of stillbirth in the third pregnancy were observed in women who had two stillbirths (adjusted odds ratio [aOR] 11.40, 95% confidence interval [95% CI] 2.75-47.70), followed by those who had stillbirth in the second birth (live birth-stillbirth) (aOR 3.59, 95% CI 2.58-4.98), but the odds were still elevated in those whose first birth ended in stillbirth (stillbirth-live birth) (aOR 2.35, 1.68, 3.28). Preterm birth, pre-eclampsia and placental abruption followed a similar pattern. The odds of having a small-for-gestational-age infant were highest in women whose first birth ended in stillbirth (aOR 1.93, 95% CI 1.66-2.24). The increased odds of having a stillbirth in a third pregnancy when either of the earlier births ended in stillbirth remained when stillbirths associated with congenital anomalies, pregestational and gestational diabetes, hypertension or preterm stillbirths were excluded. However, when preterm stillbirths were excluded, the strength of the association was reduced.

CONCLUSIONS

Even when they have had a live-born infant, women with a history of stillbirth have an increased risk of adverse pregnancy outcomes; this cannot be solely accounted for by the recurrence of congenital anomalies or maternal medical disorders. This suggests that women with a history of stillbirth should be offered additional surveillance for subsequent pregnancies.

Placental Pathology and Maternal Risk Factors for Stillbirth: A Case-Control Study

Background Fetal death is the delivery of a fetus with no sign of life, as indicated by the absence of breathing, heartbeat, pulsation of the umbilical cord, or definite movement of voluntary muscles. Nearly 2.6 million stillbirths are estimated to occur worldwide every year. Almost all of these (98%) stillbirths occur in low- and middle-income countries. About one-sixth of the stillbirths globally were recorded in India in 2019, making it the most burdened country in the world. In light of this, we conducted a study to identify the placental pathologies and maternal factors associated with stillbirth. Methodology A case-control study was conducted at the Department of Obstetrics & Gynecology, Veer Surendra Sai Institute of Medical Sciences and Research (VIMSAR), from June 2022 to May 2023. Cases included pregnant women with a gestational age of 28 weeks or more who delivered a stillbirth infant at VIMSAR, and controls included gestational age-matched deliveries with live birth. Consent to participate in the study was obtained before enrolment. The final sample size was 79 cases and controls. The chi-square test was performed for bivariate analysis, and logistic regression was used for multivariate analysis. Results In our study, we found a significant association between maternal age of more than 30 years (odds ratio (OR) = 3.01, 95% confidence interval (CI) = 1.91-4.22, p = 0.012), maternal education (with up to the primary level or less: OR = 6.19, 95% CI = 2.92-7.87, p = 0.012), history of addiction (tobacco chewing: OR = 5.58, 95% CI = 3.71-7.11, p = 0.03), and the number of antenatal visits (no visit: OR = 6.87, 95% CI = 2.91-7.79, p = 0.019) with an increased risk of stillbirth. Among the obstetrical complications, pre-eclampsia/eclampsia (OR = 3.87, 95% CI = 1.98-5.11, p = 0.001), premature rupture of membranes (PROM)/preterm premature rupture of the membranes (PPROM) (OR = 2.49, 95% CI = 1.31-3.91, p = 0.03) and antepartum hemorrhage (APH) (OR = 2.66, 95% CI = 1.65-3.58, p = 0.02) were found to be significantly related with stillbirth. Among placental pathologies, uteroplacental vascular pathology (OR = 7.39, 95% CI = 3.01-8.97), acute chorioamnionitis (OR = 3.35, 95% CI = 2.11-5.21), chronic inflammation (OR = 2.33, 95% CI = 1.91 4.17), calcific changes (OR = 4.46, 95% CI = 2.56-6.01), and retroplacental clots (OR = 9.95, 95% CI = 4.39-11.71) were associated with stillbirth. Conclusions In our study, advanced maternal age, absence of antenatal visits, low level of education, tobacco addiction, pre-eclampsia/eclampsia, APH, and PROM in pregnancy were the major risk factors associated with stillbirth. Uteroplacental vascular pathology, chorioamnionitis, chronic inflammation, retroplacental hematoma, and calcific changes were the most significant placental lesions associated with stillbirth.

Risk of recurrent stillbirth and neonatal mortality: mother-specific random effects analysis using longitudinal panel data from Indonesia (2000 - 2014)

Background

Despite significant government investments to improve birth outcomes in low and middle-income countries over the past several decades, stillbirth and neonatal mortality continue to be persistent public health problems. While they are different outcomes, there is little evidence regarding their shared and unique population-level risk factors over a mother’s reproductive lifespan. Data gaps and measurement challenges have left several areas in this field unexplored, especially assessing the risk of stillbirth or neonatal mortality over successive pregnancies to the same woman. This study aimed to assess the risk of stillbirth and neonatal mortality in Indonesia during 2000–2014, using maternal birth histories from the Indonesia Family Life Survey panel data.

Methods

Data from three panels were combined to create right-censored birth histories. There were 5,002 unique multiparous mothers with at least two singleton births in the sample. They reported 12,761 total births and 12,507 live births. Random effects (RE) models, which address the dependency of variance in births to the same mother, were fitted assuming births to the same mother shared unobserved risk factors unique to the mother.

Results

The main finding was that there having had a stillbirth increased the odds of another stillbirth nearly seven-fold and that of subsequent neonatal mortality by over two-fold. Having had a neonatal death was not associated with a future neonatal death. Mothers who were not educated and nullipara were much more likely to experience a neonatal death while mothers who had a prior neonatal death had no risk of another neonatal death due to unmeasured factors unique to the mother.

Conclusions

The results suggest that for stillbirths, maternal heterogeneity, as explained by a prior stillbirth, could capture underlying pathology while the relationship between observed risk factors and neonatal mortality could be much more dependent on context. Establishing previous adverse outcomes such as neonatal deaths and stillbirth could help identify high-risk pregnancies during prenatal care, inform interventions, and improve health policy.