Abstract
Introduction98% of the 2.6 million stillbirths per annum occur in low and middle income countries. However, understanding of risk factors for stillbirth in these settings is incomplete, hampering efforts to develop effective strategies to prevent deaths.MethodsA cross-sectional study of eligible women on the postnatal ward at Mpilo Hospital, Zimbabwe was undertaken between 01/08/2018 and 31/03/2019 (n = 1779). Data were collected from birth records for maternal characteristics, obstetric and past medical history, antenatal care and pregnancy outcome. A directed acyclic graph was constructed with multivariable logistic regression performed to fit the corresponding model specification to data comprising singleton pregnancies, excluding neonatal deaths (n = 1734), using multiple imputation for missing data. Where possible, findings were validated against all women with births recorded in the hospital birth register (n = 1847).ResultsRisk factors for stillbirth included: previous stillbirth (29/1691 (2%) of livebirths and 39/43 (91%) of stillbirths, adjusted Odds Ratio (aOR) 2628.9, 95% CI 342.8 to 20,163.0), antenatal care (aOR 44.49 no antenatal care vs. > 4 antenatal care visits, 95% CI 6.80 to 291.19), maternal medical complications (aOR 7.33, 95% CI 1.99 to 26.92) and season of birth (Cold season vs. Mild aOR 14.29, 95% CI 3.09 to 66.08; Hot season vs. Mild aOR 3.39, 95% CI 0.86 to 13.27). Women who had recurrent stillbirth had a lower educational and health status (18.2% had no education vs. 10.0%) and were less likely to receive antenatal care (20.5% had no antenatal care vs. 6.6%) than women without recurrent stillbirth.ConclusionThe increased risk in women who have a history of stillbirth is a novel finding in Low and Middle Income Countries (LMICs) and is in agreement with findings from High Income Countries (HICs), although the estimated effect size is much greater (OR in HICs ~ 5). Developing antenatal care for this group of women offers an important opportunity for stillbirth prevention.
Highlights
Despite advances in maternal and child health since the Millennium Development Goals, stillbirth remains a significant global health problem, with an estimated 2.6 million stillbirths per year, of which 98% occur in low and middle-income countries (LMICs) [1]
A further 45 births were excluded from the regression analysis because they were from multiple pregnancies (n = 26) or the baby died in the neonatal period (n = 19)
Some of these factors were validated in a sample of consecutive births taken from the birth register. This approach has enable us to identify some risk factors that have been reported previously in low-resource settings, such as lack of antenatal care, increasing maternal age, and presence of maternal medical complications. It has identified risk factors which have not been widely reported in LMICs, including previous stillbirth and seasonality
Summary
Despite advances in maternal and child health since the Millennium Development Goals, stillbirth remains a significant global health problem, with an estimated 2.6 million stillbirths per year, of which 98% occur in low and middle-income countries (LMICs) [1]. Newborn Action Plan (ENAP) has set a target that the stillbirth rate in all countries should be lower than 12 per 1000 live births by 2030 [2]. To achieve this target the annual rate of reduction needs to accelerate from 1.4 to 4% [3]. Prevention of stillbirth requires information about risk factors in order that intervention strategies can be prioritised, developed and tested. Systematic reviews of risk factors in LMICs have found a paucity of studies to inform estimates. One review including 142 studies from LMICS, found only 3 studies
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