Stillbirth rates in low-middle income countries 2010 - 2013: a population-based, multi-country study from the Global Network.

Elizabeth M Mcclure,Omrana Pasha,Pierre Buekens,Fabian Esamai,Albert Manasyan,Sarah Saleem,Elwyn Chomba,Fernando Althabe,Archana Patel,Mabel Berreuta,Ana Garcés ,Dennis Wallace ,Shivaprasad S Goudar ,Carl Bose ,Nancy F Krebs ,Marion Koso‐Thomas ,Richard J Derman ,Patricia L Hibberd ,Waldemar A Carlo ,Janet Moore ,K Michael Hambidge ,Bhalachandra S Kodkany ,Edward A Liechty ,Robert L Goldenberg

doi:10.1186/1742-4755-12-s2-s7

Abstract

BackgroundStillbirth rates remain nearly ten times higher in low-middle income countries (LMIC) than high income countries. In LMIC, where nearly 98% of stillbirths worldwide occur, few population-based studies have documented characteristics or care for mothers with stillbirths. Non-macerated stillbirths, those occurring around delivery, are generally considered preventable with appropriate obstetric care.MethodsWe undertook a prospective, population-based observational study of all pregnant women in defined geographic areas across 7 sites in low-resource settings (Kenya, Zambia, India, Pakistan, Guatemala and Argentina). Staff collected demographic and health care characteristics with outcomes obtained at delivery.ResultsFrom 2010 through 2013, 269,614 enrolled women had 272,089 births, including 7,865 stillbirths. The overall stillbirth rate was 28.9/1000 births, ranging from 13.6/1000 births in Argentina to 56.5/1000 births in Pakistan. Stillbirth rates were stable or declined in 6 of the 7 sites from 2010-2013, only increasing in Pakistan. Less educated, older and women with less access to antenatal care were at increased risk of stillbirth. Furthermore, women not delivered by a skilled attendant were more likely to have a stillbirth (RR 2.8, 95% CI 2.2, 3.5). Compared to live births, stillbirths were more likely to be preterm (RR 12.4, 95% CI 11.2, 13.6). Infants with major congenital anomalies were at increased risk of stillbirth (RR 9.1, 95% CI 7.3, 11.4), as were multiple gestations (RR 2.8, 95% CI 2.4, 3.2) and breech (RR 3.0, 95% CI 2.6, 3.5). Altogether, 67.4% of the stillbirths were non-macerated. 7.6% of women with stillbirths had cesarean sections, with obstructed labor the primary indication (36.9%).ConclusionsStillbirth rates were high, but with reductions in most sites during the study period. Disadvantaged women, those with less antenatal care and those delivered without a skilled birth attendant were at increased risk of delivering a stillbirth. More than two-thirds of all stillbirths were non-macerated, suggesting potentially preventable stillbirth. Additionally, 8% of women with stillbirths were delivered by cesarean section. The relatively high rate of cesarean section among those with stillbirths suggested that this care was too late or not of quality to prevent the stillbirth; however, further research is needed to evaluate the quality of obstetric care, including cesarean section, on stillbirth in these low resource settings.Study registrationClinicaltrials.gov (ID# NCT01073475)

Highlights

Stillbirth rates remain nearly ten times higher in low-middle income countries (LMIC) than high income countries
There is a high variation in stillbirth rates with low-income sub-Saharan African and South East Asian countries reporting the highest rates, ranging from 20 – 40 per 1000 births, nearly 10 –fold higher than those documented in high-resource settings [3,4,5]
We evaluated the maternal characteristics and obstetric and antenatal care associated with risk of stillbirth, with exploration of factors associated with macerated and intrapartum stillbirths

Summary

Introduction

Stillbirth rates remain nearly ten times higher in low-middle income countries (LMIC) than high income countries. There is a high variation in stillbirth rates with low-income sub-Saharan African and South East Asian countries reporting the highest rates, ranging from 20 – 40 per 1000 births, nearly 10 –fold higher than those documented in high-resource settings [3,4,5]. 98% of all stillbirths occur in low- and middle-income countries (LMIC), primarily in low-resource settings [1,6]. Within both high and low-resource settings, several common risk factors for stillbirths have been documented. Women with prior pregnancy losses or with complicated pregnancies, including multiple gestations, have an increased risk of stillbirth [9]

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Conclusion