Intrapartum Stillbirth Rates Research Articles

Stillbirth rates and their determinants in a national maternity hospital in Phnom Penh, Cambodia in 2017–2020: a cross-sectional assessment with a nested case–control study

BackgroundIn Cambodia, stillbirths and their underlying factors have not been systematically studied. This study aimed to assess the proportion and trends in stillbirths between 2017 and 2020 in a large maternity referral hospital in the country and identify their key determinants to inform future prevention efforts.MethodsThis was a retrospective cross-sectional analysis with a nested case–control study of women giving birth at the National Maternal and Child Health Centre (NMCHC) in Phnom Penh, 2017–2020. We calculated percentages of singleton births at ≥ 22 weeks’ gestation resulting in stillbirth and annual stillbirth rates by timing: intrapartum (fresh) or antepartum (macerated). Multivariable logistic regression was used to explore factors associated with stillbirth, where cases were all women who gave birth to a singleton stillborn baby in the 4-year period. One singleton live birth immediately following each case served as an unmatched control. Multiple imputation was used to handle missing data for gestational age.ResultsBetween 2017 and 2020, 3.2% of singleton births ended in stillbirth (938/29,742). The stillbirth rate increased from 24.8 per 1000 births in 2017 to 38.1 per 1000 births in 2020, largely due to an increase in intrapartum stillbirth rates which rose from 18.8 to 27.4 per 1000 births in the same period. The case–control study included 938 cases (stillbirth) and 938 controls (livebirths). Factors independently associated with stillbirth were maternal age ≥ 35 years compared to < 20 years (aOR: 1.82, 95%CI: 1.39, 2.38), extreme (aOR: 3.29, 95%CI: 2.37, 4.55) or moderate (aOR: 2.45, 95%CI: 1.74, 3.46) prematurity compared with full term, and small-for-gestational age (SGA) (aOR: 2.32, 1.71, 3.14) compared to average size-for-age. Breech/transverse births had nearly four times greater odds of stillbirth (aOR: 3.84, 95%CI: 2.78, 5.29), while caesarean section reduced the odds by half compared with vaginal birth (aOR: 0.50, 95%CI: 0.39, 0.64). A history of abnormal vaginal discharge increased odds of stillbirth (aOR: 1.42, 95%CI: 1.11, 1.81) as did a history of stillbirth (aOR: 3.08, 95%CI: 1.5, 6.5).ConclusionsStillbirth prevention in this maternity referral hospital in Cambodia requires strengthening preterm birth detection and management of SGA, intrapartum care, monitoring women with stillbirth history, management of breech births, and further investigation of high-risk referral cases.

Trends in Term Intrapartum Stillbirth in Norway

Fetal death during labor at term is a complication that is rarely studied in high-income countries. There is a need for large population-based studies to examine the rate of term intrapartum stillbirth in high-income countries and the factors associated with its occurrence. To evaluate trends in term intrapartum stillbirth over time and to investigate the association between the trends and term intrapartum stillbirth risk factors from 1999 to 2018 in Norway. This cohort study used data from the Medical Birth Registry of Norway from 1999 to 2018 to examine rates of term intrapartum stillbirth and risk factors associated with this event. A population of 1 021 268 term singleton pregnancies without congenital anomalies or antepartum stillbirths was included in analyses, which were performed from September 2022 to February 2023. The main exposure variable was time, which was divided into four 5-year periods: 1999 to 2003, 2004 to 2008, 2009 to 2013, and 2014 to 2018. The primary study outcome was term intrapartum stillbirth. Risk ratios were calculated, and multivariable logistic regression analyses were conducted to identify factors associated with secular trends of term intrapartum stillbirth. The study population consisted of 1 021 268 term singleton births (maternal mean [SD] age, 29.72 [5.01] years; mean [SD] gestational age, 39.69 [1.27] weeks). During the study period, there were 95 term intrapartum stillbirths (0.09 per 1000 births). Maternal age, the proportion of individuals born in a country other than Norway, and the prevalence of gestational diabetes, labor induction, operative vaginal delivery, and previous cesarean delivery increased over the course of the study period. Conversely, the prevalence of infants large for gestational age, hypertensive disorder in pregnancy, and spontaneous vaginal delivery and the proportion of individuals who smoked decreased. The term intrapartum stillbirth rate decreased by 87% (95% CI, 68%-95%) from 0.15 per 1000 births in 1999 to 2008 to 0.02 per 1000 births in 2014 to 2018. Three in 4 term intrapartum stillbirths (70 of 95) occurred during intrapartum operative deliveries. The increased prevalence of older maternal age and obstetric risk factors were not associated with the variation in intrapartum stillbirth rates among the time periods. The prevalence of term intrapartum stillbirth was higher for individuals who gave birth in maternity units with fewer than 3000 annual births (adjusted odds ratio, 1.67; 95% CI, 1.07-2.61) than for those who gave birth in units with 3000 or more annual births. Findings of this study suggest that, despite increases in maternal and obstetric risk factors, term intrapartum stillbirth rates substantially decreased during the study period. Reasons for this decrease may be due to improvements in intrapartum care.

Substantial increase in stillbirth rate during the COVID-19 pandemic: results from a population-based study in the Indian state of Bihar

IntroductionWe report on the stillbirth rate (SBR) and associated risk factors for births during the COVID-19 pandemic, and change in SBR between prepandemic (2016) and pandemic periods in the Indian...

Antepartum and intrapartum stillbirth rates across gestation: a cross-sectional study using the revised foetal death reporting system in the U.S.

BackgroundThere is a renewed call to address preventable foetal deaths in high-income countries, especially where progress has been slow. The Centers for Disease Control and Prevention released publicly, for the first time, the initiating cause and estimated timing of foetal deaths in 2014. The objective of this study is to describe risk and characteristics of antepartum versus intrapartum stillbirths in the U.S., and frequency of pathological examination to determine cause.MethodsWe conducted a cross-sectional study of singleton births (24–43 weeks) using 2014 U.S. Fetal Death and Natality data available from the National Center for Health Statistics. The primary outcome was timing of death (antepartum (n = 6200), intrapartum (n = 453), and unknown (n = 5403)). Risk factors of interest included maternal sociodemographic, behavioural, medical and obstetric factors, along with foetal sex. We estimated gestational week-specific stillbirth hazard, risk factors for intrapartum versus antepartum stillbirth using multivariable log-binomial regression models, conditional probabilities of intrapartum and antepartum stillbirth at each gestational week, and frequency of pathological examination by timing of death.ResultsThe gestational age-specific stillbirth hazard was approximately 2 per 10,000 foetus-weeks among preterm gestations and > 3 per 10,000 foetus-weeks among term gestations. Both antepartum and intrapartum stillbirth risk increased in late-term and post-term gestations. The risk of intrapartum versus antepartum stillbirth was higher among those without a prior live birth, relative to those with at least one prior live birth (RR 1.32; 95% CI 1.08–1.61) and those with gestational hypertension, relative to those with no report of gestational hypertension (RR 1.47; 95% CI 1.09–1.96), and lower among Black, relative to white, individuals (RR 0.70; 95% CI 0.55–0.89). Pathological examination was not performed/planned in 25% of known antepartum stillbirths and 29% of known intrapartum stillbirths.ConclusionThese findings suggest greater stillbirth risk in the late-term and post-term periods. Primiparous mothers had greater risk of intrapartum than antepartum still birth, suggesting the need for intrapartum interventions for primiparous mothers in this phase of pregnancy to prevent some intrapartum foetal deaths. Efforts are needed to improve understanding, prevention and investigation of foetal deaths as well as improve stillbirth data quality and completeness in the United States.

Non-infectious risk factors for intrapartum stillbirth in a swine farm in the North of Vietnam.

Background and Aims:Stillbirth causes considerable loss to the pig farming industry. Methods aimed at reducing stillbirth should base on the understanding of risk factors for intrapartum stillbirth because it accounts for 75% of all stillbirths. Unfortunately, few studies have differentiated between intrapartum and prepartum stillbirths leading to inadequate information about risk factors for sole intrapartum stillbirth. This study investigated risk factors for piglet’s intrapartum stillbirth.Materials and Methods:Data of 1527 piglets born from 103 sows in one herd were recorded. Generalized linear mixed models were used to determine the relationship between investigated risk factors and intrapartum stillbirth at the piglet level. The potential risk factors were parity, gestation length (GL), litter size (LS), birth order (BO), birth interval (BI), cumulative farrowing duration (CFD), gender, crown-rump length, birth weight (BW), body mass index, ponderal index (PI), and BW deviation.Results:About 60% (60.2%, 62/103) litters had stillborn piglet(s), and the intrapartum stillbirth rate was 5.8% (89/1527). BW deviation (≤0.1 and >0.6 kg), LS >13, GL (<114 and >117 days), PI ≤54, and BO >10 were the most significant factors associated with increased intrapartum stillbirth. No effect of parity, sex, BI, and CFD on intrapartum stillbirth was detected.Conclusion:These data stressed the importance of piglets’ size and shape in the prediction of intrapartum stillbirth. Furthermore, large LS, high BO, short, and long GL were associated with increased intrapartum stillbirth. The results of this study suggest that procedures aimed at increasing litter homogeneity, optimizing piglets’ size and shape, avoiding short and long gestation, and increasing supervision rate, especially at the second half, of the farrowing may reduce piglet’s intrapartum stillbirth.

Every Caesarean Section Must Count

(Aust N Z J Obstet Gynaecol. 2016;56(5):450–452) This opinion piece supports the argument that cesarean section rates (CSR) are an essential indicator of the quality of care and should be monitored. Between 1985 and 2013 the CSR increased from 15% to 32.8%—more than a doubling in &lt;3 decades. Arguments against the monitoring of CSR include the rights of women to opt for the procedure, high intrapartum stillbirth rates, and the preventable burden of lifelong disabilities caused by intrapartum asphyxia and perineal lacerations resulting from vaginal deliveries. Yet, the risks associated with cesarean section (CS) and the potential morbidity as a result of an increased CSR support making sure each CS is indicated.

Neonatal resuscitation in global health settings: an examination of the past to prepare for the future.

As rates of childhood mortality decline, neonatal deaths account for nearly half of under-5 deaths worldwide. Intrapartum-related events (birth asphyxia) contribute to approximately one-quarter of neonatal deaths, many of which can be prevented by simple resuscitation and newborn care interventions. This paper reviews various lines of research that have influenced the global neonatal resuscitation landscape. A brief situational analysis of asphyxia-related newborn mortality in low-resource settings is linked to renewed efforts to reduce neonatal mortality in the Every Newborn Action Plan. Possible solutions to gaps in care are identified. Building on international scientific evidence, tests of educational efficacy, and community-based trials established the feasibility and effectiveness of training in resource-limited settings and identified successful implementation strategies. Implementation of neonatal resuscitation programs has been shown to decrease intrapartum stillbirth rates and early neonatal mortality. Challenges remain with respect to provider competencies, coverage, and quality of interventions. The combination of resuscitation science, strategies to increase educational effectiveness, and implemention of interventions with high coverage and quality has resulted in reduced rates of asphyxia-related neonatal mortality. Further efforts to improve coverage and implementation of neonatal resuscitation will be necessary to meet the 2035 goal of eliminating preventable newborn deaths.

Reducing Perinatal Mortality in Nepal Using Helping Babies Breathe.

Newborns are at the highest risk of dying around the time of birth, due to intrapartum-related complications. Our study's objective was to improve adherence to the Helping Babies Breathe (HBB) neonatal resuscitation protocol and reduce perinatal mortality by using a quality improvement cycle (QIC) in a tertiary hospital in Nepal. The HBB QIC was implemented through a multifaceted approach, including the formation of quality improvement teams; development of quality improvement goals, objectives, and standards; HBB protocol training; weekly review meetings; daily skill checks; use of self-evaluation checklists; and refresher training. A cohort design, including a nested case-control study was used to measure changes in clinical outcomes and adherence to the resuscitation protocol through video recording, before and after implementation of the QIC. The intrapartum stillbirth rate decreased from 9.0 to 3.2 per thousand deliveries, and first-day mortality from 5.2 to 1.9 per thousand live births after intervention, demonstrating a reduction of approximately half in the odds of intrapartum stillbirth (adjusted odds ratio [OR] 0.46, 95% confidence interval [CI] 0.32-0.66) and first-day mortality (adjusted OR 0.51, 95% CI 0.31-0.83). After intervention, the odds of inappropriate use of suction and stimulation decreased by 87% (OR 0.13, 95% CI 0.09-0.17) and 62% (OR 0.38, 95% CI 0.29-0.49), respectively. Before intervention, none of the infants received bag-and-mask ventilation within 1 minute of birth, compared with 83.9% of infants after. The HBB QIC reduced intrapartum stillbirth and first-day neonatal mortality and led to use of suctioning and stimulation more frequently. The HBB QIC requires further testing in primary settings across Nepal.

PP.43 Perinatal Outcomes and Travel Time to Maternity Services: Analysis of Birth Outcome Data in Wales from 1995 to 2009

ObjectiveTo study the association between travel time from home to hospital on intrapartum stillbirth and neonatal mortality.PopulationAll births to women who were resident in Wales between 1995 – 2009 (n...

Two million intrapartum-related stillbirths and neonatal deaths: Where, why, and what can be done?

BackgroundIntrapartum-related neonatal deaths (“birth asphyxia”) are a leading cause of child mortality globally, outnumbering deaths from malaria. Reduction is crucial to meeting the fourth Millennium Development Goal (MDG), and is intimately linked to intrapartum stillbirths as well as maternal health and MDG 5, yet there is a lack of consensus on what works, especially in weak health systems. ObjectiveTo clarify terminology for intrapartum-related outcomes; to describe the intrapartum-related global burden; to present current coverage and trends for care at birth; and to outline aims and methods for this comprehensive 7-paper supplement reviewing strategies to reduce intrapartum-related deaths. ResultsBirth is a critical time for the mother and fetus with an estimated 1.02 million intrapartum stillbirths, 904000 intrapartum-related neonatal deaths, and around 42% of the 535900 maternal deaths each year. Most of the burden (99%) occurs in low- and middle-income countries. Intrapartum-related neonatal mortality rates are 25-fold higher in the lowest income countries and intrapartum stillbirth rates are up to 50-fold higher. Maternal risk factors and delays in accessing care are critical contributors. The rural poor are at particular risk, and also have the lowest coverage of skilled care at birth. Almost 30000 abstracts were searched and the evidence is evaluated and reported in the 6 subsequent papers. ConclusionEach year the deaths of 2 million babies are linked to complications during birth and the burden is inequitably carried by the poor. Evidence-based strategies are urgently needed to reduce the burden of intrapartum-related deaths particularly in low- and middle-income settings where 60 million women give birth at home.

Intrapartum stillbirth in a Nigerian tertiary hospital setting

Objective To examine the nonmedical events contributing to intrapartum stillbirths in an African setting. Methods Retrospective analysis of the records of women who had intrapartum stillbirths at the University of Nigeria Teaching Hospital, Enugu, from January 1999 to December 2007. The events surrounding the delivery of these women were critically analyzed and statistically compared with those who had live births to determine the nonmedical factors contributing to the stillbirths. Results The overall stillbirth rate was 89 per 1000 births. The intrapartum stillbirth rate was 52.1 per 1000 births. Nonmedical factors contributing to stillbirths included delays in receiving appropriate management, inadequate intrapartum monitoring, inappropriate interventions, and wrong diagnosis. All 3 types of delay were significantly associated with intrapartum stillbirth ( P = 0.0001). Conclusion Intrapartum stillbirth accounts for the majority of stillbirths in this setting. Avoidable delays, suboptimal intrapartum monitoring, and inappropriate interventions contribute to the majority of intrapartum stillbirths in Nigeria.

The relationship of intrapartum and antepartum stillbirth rates to measures of obstetric care in developed and developing countries

The objective of this study was to explore the relationship between intrapartum and antepartum stillbirths and various measures of obstetric care in developing and developed countries. For 51 countries, we obtained data about intrapartum and antepartum stillbirth rates and obstetric care measures from the World Health Organisation (WHO) and other sources. Using piecewise regression techniques, the relationships between the intrapartum and antepartum stillbirth rates and the various measures of obstetric care were determined. Developed countries had lower total stillbirth rates (6.0 versus 21.3/1,000 births, p=0.0002) as well as a lower fraction of stillbirths that were intrapartum (0.16 versus 0.31, p=0.0019). Developed country antepartum stillbirth rates were 5.2 versus 14.0/1,000 in developing countries (p=0.0002). The highest antepartum stillbirth rates, all in southern Africa and Asia, ranged from 25 to 35/1,000 births. Intrapartum stillbirth rates averaged 0.9/1,000 births for developed countries compared to 7.3/1,000 in developing countries (p=0.0024), but ranged as high as 20-25/1,000 births for some countries in southern Africa and Asia. The relationship between intrapartum stillbirth and the various measures of care were generally stronger than those for antepartum stillbirth. Over the entire range of values, for each 1% increase in the percentage of women with at least 4 antenatal visits, the intrapartum stillbirth rate decreased by 0.16 per 1,000 births (p<0.0001). As cesarean section rates increased from 0 to 8%, for each 1% increase, there was a decrease of 1.61 intrapartum stillbirths per 1,000 births. There was no relationship between the cesarean section rates and intrapartum stillbirth rates in developed countries. The intrapartum stillbirth rate is more closely related to various measures of obstetric care than the antepartum stillbirth rate. Increases in cesarean section rates up to 8% are associated with significant improvements in intrapartum stillbirth rates.

Safety and place of birth in Scotland

The recent publication of policies suggesting women should have choice about where they give birth prompted a comparison of stillbirth and neonatal mortality rates for three types of maternity unit in relation to changes in booking and place of delivery. Scottish Maternity Discharge records and data from stillbirth and neonatal death reports for Scotland were used to analyse stillbirth and neonatal mortality rates according to the level of care, birthweight and cause of death for the years 1986-1990. For those categories of stillbirths and neonatal deaths which are amenable to prevention by perinatal care, intrapartum stillbirth rates were higher in general practitioner (GP) units than in consultant units, but these accounted for only 11 stillbirths and the difference is compatible with chance variation. Neonatal mortality among babies weighting 2500 g or more was independent of type of hospital. Among babies weighing under 1500 g or 1500-2499 g, neonatal mortality was significantly higher in non-teaching hospitals than in teaching hospitals. Although the differences are compatible with chance variation, there is some suggestion that small GP hospitals might have higher rates of intrapartum stillbirths and such rates should be monitored. Provided that there are no barriers to transfer to hospitals with consultant units when appropriate, there is no evidence that these small GP hospitals are unsafe. The high neonatal mortality rates, especially among babies weighing 1500-2499 g in non-teaching consultant units, compared with teaching units, should be investigated further.

Stillbirths in Western Australia 1980-1983: influence of race, residence and place of birth.

All stillbirths in Western Australia from 1980-83 weighing 1,000 g and over were identified from perinatal death certificates, and their causes and demographic correlates described. The stillbirth rate was 4.91 per 1,000 total births; nearly 65% were antepartum, 25% intrapartum and in 10% the time of death was unknown. The cause of death of most stillbirths was unknown (52%) or associated with lethal congenital malformations (13%), antepartum haemorrhage (12%) or maternal hypertension (8%). Whilst Aboriginal women had much higher stillbirth rates (10.80) than non-Aboriginal women (4.57), their patterns of time and causes of death were similar. Both antepartum and intrapartum stillbirth rates were much higher at low birth-weights and low gestational ages in both racial groups. Women living in rural areas who delivered in the metropolitan area had much higher antepartum (11.02) and intrapartum (3.31) stillbirth rates than either rural women delivering in rural areas (1.89 and 1.34) or metropolitan women delivering in the metropolitan area (2.72, 0.98). This reflects the transfer of rural high risk pregnant women or those with fetal death in utero, for delivery in metropolitan specialist hospitals.

Changing patterns of perinatal and infant mortality in Western Australia: implications for prevention.

Perinatal and infant mortality rates have fallen dramatically in the developed world this century. A review of perinatal and infant mortality in Western Australia from 1970 to 1981 was undertaken, to examine trends in birthweight-specific and cause-specific rates. The predominant causes of death are now congenital malformation, stillbirth of unknown cause, preterm birth and cot death. Perinatal and infant mortality rates are unlikely to be reduced substantially until the reasons for these four causes of death are elucidated.

Effects of Monitoring High‐Risk Pregnancies and Intrapartum FHR Monitoring on Perinates

A protocol of chronic antepartum surveillance was initiated at the University of Illinois hospitals in 1973 to assess the impact on perinatal mortality. At the same time, a policy of unselected fetal heart rate (FHR) monitoring was initiated to judge the effect on the intrapartum stillbirth rate. The impact of both programs played a significant role in the decline of perinatal mortality rates for infants weighing more than 1 500 g, from 21.1/1 000 births in 1970--1971 to 14.4/1 000 births in the monitored years 1973 and 1974 (p less than 0.02).