Intrapartum Stillbirths Research Articles

Exploring the potential cost-effectiveness of a new computerised decision support tool for identifying fetal compromise during monitored term labours: an early health economic model

BackgroundAround 60% of term labours in the UK are continuously monitored using cardiotocography (CTG) to guide clinical labour management. Interpreting the CTG trace is challenging, leading to some babies suffering adverse outcomes and others unnecessary expedited deliveries. A new data driven computerised tool combining multiple clinical risk factors with CTG data (attentive CTG) was developed to help identify term babies at risk of severe compromise during labour. This paper presents an early health economic model exploring its potential cost-effectiveness.MethodsThe model compared attentive CTG and usual care with usual care alone and simulated clinical events, healthcare costs, and infant quality-adjusted life years over 18 years. It was populated using data from a cohort of term pregnancies, the literature, and administrative datasets. Attentive CTG effectiveness was projected through improved monitoring sensitivity/specificity and potential reductions in numbers of severely compromised infants. Scenario analyses explored the impact of including litigation costs.ResultsNationally, attentive CTG could potentially avoid 10,000 unnecessary alerts in labour and 2400 emergency C-section deliveries through improved specificity. A reduction of 21 intrapartum stillbirths amongst severely compromised infants was also predicted with improved sensitivity. Attentive CTG could potentially lead to cost savings and health gains with a probability of being cost-effective at £25,000 per QALY ranging from 70 to 95%. Potential exists for further cost savings if litigation costs are included.ConclusionsAttentive CTG could offer a cost-effective use of healthcare resources. Prospective patient-level studies are needed to formally evaluate its effectiveness and economic impact in routine clinical practice.

Perinatal mortality among term births: Informing decisions about singleton early term births in Western Australia.

To minimise the risk of perinatal mortality, clinicians and expectant mothers must understand the risks and benefits associated with continuing the pregnancy. Report the gestation-specific risk of perinatal mortality at term. Population-based cohort study using linked health data to identify all singleton births at gestations 37-41 weeks, in Western Australia (WA) from 2009 to 2019. Lifetable analysis was used to combine the risk of each type of perinatal mortality and calculate the cumulative risk of perinatal mortality, termed the perinatal risk index (PRI). Rates of antepartum and intrapartum stillbirth and neonatal death, as well as the PRI, were examined for each gestational week at term by non-Aboriginal and Aboriginal ethnicity. For non-Aboriginal women, rates were also examined by time-period (pre- vs. post-WA Preterm Birth Prevention Initiative (the Initiative) rollout), primiparity, and obstetric risk. There were 332,084 singleton term births, including 60 perinatal deaths to Aboriginal mothers (3.2 deaths per 1000 births to Aboriginal mothers) and 399 perinatal deaths to non-Aboriginal mothers (1.3 deaths per 1000 births to non-Aboriginal mothers). For non-Aboriginal women, the PRI was at its lowest (PRI 0.80, 95% CI 0.61, 1.00) at 39 weeks gestation. For Aboriginal women, it was at its lowest at 38 weeks (PRI 2.43, 95% CI 0.48, 4.39) with similar risk at 39 weeks (PRI 2.68, 95% CI 1.22, 4.14). The PRI increased steadily after 39 weeks gestation. The risk of perinatal mortality was higher among Aboriginal women. The gestation-specific perinatal mortality rates were similar by the time-period, primiparity and obstetric risk. The gestational ages at term associated with the lowest risk of perinatal mortality reinforce that the recommendation not to deliver before 39 weeks without medical indication is applicable to both Aboriginal and non-Aboriginal women giving birth in WA. There was no increase in the perinatal mortality rate associated with the introduction of the Initiative.

Elective induction of labor versus expectant management at 39 weeks among low-risk nulliparous pregnant women: A randomized controlled trial in India (ELITE-39 trial).

The aim of the present open label randomized controlled trial was to compare the rate of cesarean section (CS) after elective induction with that of expectant management in low-risk nulliparous women at 39 weeks. This randomized controlled trial from a tertiary maternity care center enrolled low risk nulliparous pregnant women at 38-38+4 weeks between April 1, 2019 and December 31, 2021. Participants were randomized into either the elective induction group (e-IOL) or the expectant management (EM) group though computer generated block randomization. The primary outcome was cesarean rate and the secondary outcome include adverse maternal and perinatal outcome between e-IOL and EM groups. We performed intention to treat analysis. A total of 360 women were enrolled into the present study. Analysis was performed for 179 women in the e-IOL group and 180 women in the EM group. The baseline demographic characteristics including Bishop score were comparable between the groups. The CS rate in both groups was 17.3% (31/179) and 25% (45/180), which is comparable (P = 0.08). There was one intrapartum stillbirth in the e-IOL group, and two babies succumbed in the neonatal period in the EM group. The maternal and perinatal outcomes between the groups were not found to be significantly different. Elective induction of low-risk nulliparous women at 39 weeks was not associated with increased cesarean section rate. The maternal and perinatal outcomes were comparable. Large, multicentric real time randomized controlled trials are needed to understand the benefit of elective induction in low-risk nulliparous women. This should include centers with large volume of deliveries especially from emerging countries also.

Is it possible to detect women at higher risk of intrapartum stillbirth? An area-based prospective cohort study.

The aim of the study is to perform an overview of intrapartum stillbirth (SB) at term, assessing risk factors, causes of death and quality of pregnancy care. This is an area-based, prospective cohort study on pregnant women at ≥37 weeks from 2014 to 2021. We compared intrapartum SB' information to alive birth and to antepartum deaths of the same period. Results of logistic regression are reported as the Odds Ratio (OR) with 95% confidence interval (95% CI) and the P value. A descriptive analysis about the causes of death and quality of pregnancy care is performed. The overall rate of SB at term in Emilia-Romagna was 1.06 ‰ births. Among the 260 cases, 27 (10.4%) occurred during labor, with an intrapartum SB rate of 0.11‰. This SB rate was stable during years. SGA newborn (P=0.005, 95% CI 1.47-9.04, OR 3.63), low level of education (P<0.0001, 95% CI 2.98-16.11, OR 6.93), pre pregnancy BMI ≥ 25 kg/m2 (P<0.0001, 95% CI 6.61-31.74, OR 14.50) are independent risk factors for intrapartum SB when compared to alive newborns. Compared with antepartum SB, excessive weight gain in pregnancy (RR 2.91, 1.43-3.98, P=0.001) represents a risk factor for intrapartum ones. Preventing intrapartum SB at term in developed country should be based on both the appropriate antenatal management of fetal growth and the avoidance of maternal excessive weight gain. An effort toward pre conceptional intervention of improving maternal shape could be of value.

Epidemiology of intrapartum stillbirth and associated factors among women who gave childbirth in Ethiopia: systematic review and meta-analysis

BackgroundStillbirth always resulted in a multi-dimensional impact from the individual level to the country level at large. It causes psychological depression, social stigmatization, and decreased quality of life for women. Despite several studies conducted in Ethiopia, no national pooled estimates were done. Therefore, this systematic review and meta-analysis sought to assess intrapartum stillbirth and associated factors among women who had childbirth in Ethiopia using the available published evidence.MethodsThe current review included studies conducted in Ethiopia. The databases used primarily were Medline/PubMed, Google Scholar, Scopus, Web of Science, Ethiopian University Repository Online, CINAHL, African Journals Online and Cochrane Library. All cross-sectional studies conducted in English and met eligibility criteria were included in the final review. A random-effects meta-analysis was performed. Data extraction and analysis were also performed using Microsoft Excel and STATA version 14 software respectively.ResultsIn the current review, eleven studies were included, and their quality was assessed before being chosen for the final review. The pooled prevalence of intrapartum stillbirth among women who had childbirth in Ethiopia was 9.21% [95% CI (7.03%, 11.39%); I2 = 90.2, P = 0.000]. Women with a previous history of stillbirth [OR = 5.14, 95% CI (3.53–6.75), I2 = 60.0%, p = 0.04] and had no use of antenatal care {[OR = 0.43, 95% CI (0.18–0.68) I2 = 85.3%, p = 0.001]} were significantly associated with intrapartum stillbirth among women who gave childbirth. ConclusionsNearly one-tenth of women who had childbirth in Ethiopia had an intrapartum SB. Revitalizing the existing health extension package particularly family health services with emphasis on focused antenatal care and counselling as well as with prompt referral system would reduce intrapartum SB. This review calls for the need to assess the quality of ANC provision and tailor targeted interventions to best improve the service quality.

A time-stratified, case-crossover study of heat exposure and perinatal mortality from 16 hospitals in sub-Saharan Africa.

Growing evidence suggests that extreme heat events affect both pregnant women and their infants, but few studies are available from sub-Saharan Africa. Using data from 138,015 singleton births in 16 hospitals in Benin, Malawi, Tanzania and Uganda, we investigated the association between extreme heat and early perinatal deaths, including antepartum and intrapartum stillbirths, and deaths within 24 h after birth using a time-stratified case-crossover design. We observed an association between an increase from the 75th to the 99th percentile in mean temperature 1 week (lag 0-6 d) before childbirth and perinatal mortality (odds ratio (OR) = 1.34 (95% confidence interval (CI) 1.01-1.78)). The estimates for stillbirths were similarly positive, but CIs included unity: OR = 1.29 (95% CI 0.95-1.77) for all stillbirths, OR = 1.18 (95% CI 0.71-1.95) for antepartum stillbirths and OR = 1.64 (95% CI 0.74-3.63) for intrapartum stillbirths. The cumulative exposure-response curve suggested that the steepest slopes for heat for intrapartum stillbirths and associations were stronger during the hottest seasons. We conclude that short-term heat exposure may increase mortality risks, particularly for intrapartum stillbirths, raising the importance of improved intrapartum care.

A hybrid approach to skill retention following neonatal resuscitation training: Assessing effectiveness.

Perinatal death, a global health problem, can be prevented with simple resuscitation interventions that help the baby breathe immediately at birth. Latter-day Saint Charities (LDSC) and Safa Sunaulo Nepal (SSN) implemented a program to scale-up Helping Babies Breathe (HBB) training in Karnali Province, Nepal from January 2020-February 2021. The interventions were implemented using a hybrid approach with on-site mentoring in the pre/post COVID period combined with remote support and monitoring during the COVID period. This paper reports overall changes in newborn outcomes in relation to the unique implementation approach used. A prospective cohort design was used to compare outcomes of birth cohorts in 16 public health facilities in the first and last three months of program implementation. Results showed significant decreases in intrapartum stillbirths (23%), and neonatal deaths within (27%) and after (41.3%) 24 hours of life. The scale-up of HBB training resulted in 557 providers receiving training and mentoring support during the program period, half trained during the COVID period. Increased practice sessions, review meetings and debriefing meetings were reported during the COVID period compared to pre/post COVID period. The evaluation is suggestive of the potential of a hybrid approach for improved perinatal outcomes and scaling-up of newborn resuscitation trainings in health system facing disruptions.

Stillbirth mortality by Robson ten-group classification system: A cross-sectional registry of 80 663 births from 16 hospital in sub-Saharan Africa.

To assess stillbirth mortality by Robson ten-group classification and the usefulness of this approach for understanding trends. Cross-sectional study. Prospectively collected perinatal e-registry data from 16 hospitals in Benin, Malawi, Tanzania and Uganda. All women aged 13-49 years who gave birth to a live or stillborn baby weighting >1000 g between July 2021 and December 2022. We compared stillbirth risk by Robson ten-group classification, and across countries, and calculated proportional contributions to mortality. Stillbirth mortality, defined as antepartum and intrapartum stillbirths. We included 80 663 babies born to 78 085 women; 3107 were stillborn. Stillbirth mortality by country were: 7.3% (Benin), 1.9% (Malawi), 1.6% (Tanzania) and 4.9% (Uganda). The largest contributor to stillbirths was Robson group 10 (preterm birth, 28.2%) followed by Robson group 3 (multipara with cephalic term singleton in spontaneous labour, 25.0%). The risk of dying was highest in births complicated by malpresentations, such as nullipara breech (11.0%), multipara breech (16.7%) and transverse/oblique lie (17.9%). Our findings indicate that group 10 (preterm birth) and group 3 (multipara with cephalic term singleton in spontaneous labour) each contribute to a quarter of stillbirth mortality. High mortality risk was observed in births complicated by malpresentation, such as transverse lie or breech. The high mortality share of group 3 is unexpected, demanding case-by-case investigation. The high mortality rate observed for Robson groups 6-10 hints for a need to intensify actions to improve labour management, and the categorisation may support the regular review of labour progress.

Determinants of obstructed labour and associated outcomes in referral hospitals in Nigeria.

To estimate the prevalence of obstructed labour, associated risk factors and outcomes across a network of referral hospitals in Nigeria. Retrospective observational study. A total of 54 referral-level hospitals across the six geopolitical regions of Nigeria. Pregnant women who were diagnosed with obstructed labour during childbirth and subsequently underwent an emergency caesarean section between 1 September 2019 and 31 August 2020. Secondary analysis of routine maternity care data sets. Random-effects multivariable logistic regression was used to ascertain the factors associated with obstructed labour. Risk factors for obstructed labour and related postpartum complications, including intrapartum stillbirth, maternal death, uterine rupture, postpartum haemorrhage and sepsis. Obstructed labour was diagnosed in 1186 (1.7%) women. Among these women, 31 (2.6%) cases resulted in maternal death and 199 (16.8%) cases resulted in postpartum complications. Women under 20 years of age (OR 2.03, 95% CI 1.50-2.75), who lacked formal education (OR 1.88, 95% CI 1.55-2.30), were unemployed (OR 1.94, 95% CI 1.57-2.41), were nulliparous (OR 2.11, 95% CI 1.83-2.43), did not receive antenatal care (OR 3.34, 95% CI 2.53-4.41) or received antenatal care in an informal healthcare setting (OR 8.18, 95% CI 4.41-15.14) were more likely to experience obstructed labour. Ineffective referral systems were identified as a major contributor to maternal death. Modifiable factors contributing to the prevalence of obstructed labour and associated adverse outcomes in Nigeria can be addressed through targeted policies and clinical interventions.

Uncovering the causes and socio-demographic constructs of stillbirths and neonatal deaths in an urban slum of Karachi.

Neonatal deaths and stillbirths are significant public health concerns in Pakistan, with an estimated stillbirth rate of 43 per 1,000 births and a neonatal mortality rate of 46 deaths per 1,000 live births. Limited access to obstetric care, poor health seeking behaviors and lack of quality healthcare are the leading root causes for stillbirths and neonatal deaths. Rehri Goth, a coastal slum in Karachi, faces even greater challenges due to extreme poverty, and inadequate infrastructure. This study aims to investigate the causes and pathways leading to stillbirths and neonatal deaths in Rehri Goth to develop effective maternal and child health interventions. A mixed-method cohort study was nested with the implementation of large maternal, neonatal and child health program, captured all stillbirths and neonatal death during the period of May 2014 till June 2018. The Verbal and Social Autopsy (VASA) tool (WHO 2016) was used to collect primary data from all death events to determine the causes as well as the pathways. Interviews were conducted both retrospectively and prospectively with mothers and caregivers. Two trained physicians reviewed the VASA form and the medical records (if available) and coded the cause of death blinded to each other. Descriptive analysis was used to categorize stillbirth and neonatal mortality data into high- and low-mortality clusters, followed by chi-square tests to explore associations between categories, and concluded with a qualitative analysis. Out of 421 events captured, complete VASA interviews were conducted for 317 cases. The leading causes of antepartum stillbirths were pregnancy-induced hypertension (22.4%) and maternal infections (13.4%), while obstructed labor was the primary cause of intrapartum stillbirths (38.3%). Neonatal deaths were primarily caused by perinatal asphyxia (36.1%) and preterm birth complications (27.8%). The qualitative analysis on a subset of 40 death events showed that health system (62.5%) and community factors (37.5%) contributing to adverse outcomes, such as delayed referrals, poor triage systems, suboptimal quality of care, and delayed care-seeking behaviors. The study provides an opportunity to understand the causes of stillbirths and neonatal deaths in one of the impoverished slums of Karachi. The data segregation by clusters as well as triangulation with qualitative analysis highlight the needs of evidence-based strategies for maternal and child health interventions in disadvantaged communities.

Social distancing and extremely preterm births in the initial COVID-19 pandemic period

HypothesisIncreased social distancing was associated with a lower incidence of extremely preterm live births (EPLB) during the initial COVID-19 pandemic period.Study designProspective study at the NICHD Neonatal Research Network sites comparing EPLB (220/7–286/7 weeks) and extremely preterm intrapartum stillbirths (EPIS) rates during the pandemic period (March-July, weeks 9–30 of 2020) with the reference period (same weeks in 2018 and 2019), correlating with state-specific social distancing index (SDI).ResultsEPLB and EPIS percentages did not significantly decrease (1.58–1.45%, p = 0.07, and 0.08–0.06%, p = 0.14, respectively). SDI was not significantly correlated with percent change of EPLB (CC = 0.29, 95% CI = −0.12, 0.71) or EPIS (CC = −0.23, 95% CI = −0.65, 0.18). Percent change in mean gestational age was positively correlated with SDI (CC = 0.49, 95% CI = 0.07, 0.91).ConclusionsIncreased social distancing was not associated with change in incidence of EPLB but was associated with a higher gestational age of extremely preterm births.ClinicalTrials.gov IDGeneric Database: NCT00063063.

District health management and stillbirth recording and reporting: a qualitative study in the Ashanti Region of Ghana

BackgroundDespite global efforts to reduce maternal and neonatal mortality, stillbirths remain a significant public health challenge in many low- and middle-income countries. District health systems, largely seen as the backbone of health systems, are pivotal in addressing the data gaps reported for stillbirths. Available, accurate and complete data is essential for District Health Management Teams (DHMTs) to understand the burden of stillbirths, evaluate interventions and tailor health facility support to address the complex challenges that contribute to stillbirths. This study aims to understand stillbirth recording and reporting in the Ashanti Region of Ghana from the perspective of DHMTs.MethodsThe study was conducted in the Ashanti Region of Ghana. 15 members of the regional and district health directorates (RHD/DHD) participated in semi-structured interviews. Sampling was purposive, focusing on RHD/DHD members who interact with maternity services or stillbirth data. Thematic analyses were informed by an a priori framework, including theme 1) experiences, perceptions and attitudes; theme 2) stillbirth data use; and theme 3) leadership and support mechanisms, for stillbirth recording and reporting.ResultsUnder theme 1, stillbirth definitions varied among respondents, with 20 and 28 weeks commonly used. Fresh and macerated skin appearance was used to classify timing with limited knowledge of antepartum and intrapartum stillbirths. For theme 2, data quality checks, audits, and the district health information management system (DHIMS-2) data entry and review are functions played by the DHD. Midwives were blamed for data quality issues on omissions and misclassifications. Manual entry of data, data transfer from the facility to the DHD, limited knowledge of stillbirth terminology and periodic closure of the DHIMS-2 were seen to proliferate gaps in stillbirth recording and reporting. Under theme 3, perinatal audits were acknowledged as an enabler for stillbirth recording and reporting by the DHD, though audits are mandated for only late-gestational stillbirths (> 28 weeks). Engagement of other sectors, e.g., civil/vital registration and private health facilities, was seen as key in understanding the true population-level burden of stillbirths.ConclusionEffective district health management ensures that every stillbirth is accurately recorded, reported, and acted upon to drive improvements. A large need exists for capacity building on stillbirth definitions and data use. Recommendations are made, for example, terminology standardization and private sector engagement, aimed at reducing stillbirth rates in high-mortality settings such as Ghana.

Risk of stillbirth after a previous caesarean delivery: A Swedish nationwide cohort study.

To investigate the risk of stillbirth in relation to (1) a previous caesarean delivery (CD) compared with those following a vaginal birth (VB); and (2) vaginal birth after caesarean (VBAC) compared with a repeat CD. Population-based cohort study. The Swedish Medical Birth registry. Women with their first and second singletons between 1982 and 2012. Multivariable logistic regression models were performed to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of the association between CD in the first pregnancy and stillbirth in the second pregnancy and the association between VBAC and stillbirth. Sub-group analyses were performed by types of CD and timing of stillbirth (antepartum and intrapartum). Stillbirth (antepartum and intrapartum fetal death). Of the 1 771 700 singleton births from 885 850 women, 117 114 (13.2%) women had a CD in the first pregnancy, and 51 755 had VBAC in the second pregnancy. We found a 37% increased odds of stillbirth (aOR 1.37; 95% CI 1.23-1.52) in women with a previous CD compared with VB. The odds of intrapartum stillbirth were higher in the previous pre-labour CD group (aOR 2.72; 95% CI 1.51-4.91) and in the previous in-labour CD group (aOR 1.35; 95% CI 0.76-2.40), although not statistically significant in the latter case. No increased odds were found for intrapartum stillbirth in women who had VBAC (aOR 0.99; 95% CI 0.48-2.06) compared with women who had a repeat CD. This study confirms that a CD is associated with an increased risk of subsequent stillbirth, with a greater risk among pre-labour CD. This association is not solely mediated by increases in intrapartum asphyxia, uterine rupture or attempted VBAC. Further research is needed to understand this association, but these findings might help healthcare providers to reach optimal decisions regarding mode of birth, particularly when CD is unnecessary.

Maternal near miss as a predictor of adverse perinatal outcomes: findings from a prospective cohort study in southwestern Uganda

BackgroundDespite efforts, Uganda has not met the World Health Organization target of < 12 newborn deaths per 1,000 live births. Severe maternal morbidity or ‘near miss’ is a major contributor to adverse perinatal outcomes, particularly in low-resource settings. However, the specific impact of maternal near miss on perinatal outcomes in Uganda remains insufficiently investigated. We examined the association between maternal near miss and adverse perinatal outcomes at Mbarara Regional Referral Hospital (MRRH) in southwestern Uganda.MethodsWe conducted a prospective cohort study among women admitted for delivery at MRRH’s maternity ward from April 2022 to August 2022. We included mothers at ≥ 28 weeks of gestation with singleton pregnancies, while intrauterine fetal death cases were excluded. For the near-miss group, we consecutively included mothers with any one of the following: antepartum hemorrhage with shock, uterine rupture, hypertensive disorders, coma, and cardiac arrest; those without these complications constituted the non-near-miss group. We followed the mothers until delivery, and their infants until seven days postpartum or death. Adverse perinatal outcomes considered were low birth weight (< 2,500 g), low Apgar score (< 7 at five minutes), intrapartum stillbirths, early neonatal death, or admission to neonatal intensive care unit. Multivariable log-binomial regression was used to determine predictors of adverse perinatal outcomes.ResultsWe enrolled 220 participants (55 maternal near misses and 165 non-near misses) with a mean age of 27 ± 5.8 years. Most of the near misses were pregnancies with hypertensive disorders (49%). Maternal near misses had a four-fold (adjusted risk ratio [aRR] = 4.02, 95% CI: 2.32–6.98) increased risk of adverse perinatal outcomes compared to non-near misses. Other predictors of adverse perinatal outcomes were primigravidity (aRR = 1.53, 95%CI: 1.01–2.31), and gestational age < 34 weeks (aRR = 1.81, 95%CI: 1.19–2.77).ConclusionMaternal near misses, primigravidity, and preterm pregnancies were independent predictors of adverse perinatal outcomes in this study. We recommend implementing maternal near-miss surveillance as an integral component of comprehensive perinatal care protocols, to improve perinatal outcomes in Uganda and similar low-resource settings. Targeted interventions, including specialized care for women with maternal near misses, particularly primigravidas and those with preterm pregnancies, could mitigate the burden of adverse perinatal outcomes.

Rates and risk factors for antepartum and intrapartum stillbirths in 20 secondary hospitals in Imo state, Nigeria: A hospital-based case control study.

Despite Nigeria's stillbirth rate reducing from 28.6 to 22.5 per 1,000 births from 2000-2021, progress trails comparable indicators and regional variations persist. We assessed stillbirth incidences and associated risk factors in 20 secondary hospitals in Imo state, to generate essential local evidence to inform policymaking to reduce mortality. The total numbers of births and their outcomes were determined through hospital maternity registers. An unmatched case-control study was conducted. We collected retrospective data about 157 antepartum and 193 intrapartum stillbirths, and from 381 livebirths (controls). Potential risk factors were categorised into sociodemographic, obstetric and maternity care and biological determinants using a theoretical framework. Independent multivariable logistic regression models were used to investigate the association of risk factors with each stillbirth type. The overall stillbirth rate was 38 per 1,000 total births. The rate of antepartum and intrapartum stillbirths were 16 and 19 per 1,000 respectively. The risk factors independently associated with antepartum stillbirths were nulliparity (adjusted odds ratio (aOR) 1.87, 95%CI 1.04-3.36); preterm birth (aOR 14.29, 95%CI 6.31-32.38); being referred from another facility (aOR 3.75, 95%CI 1.96-7.17); unbooked pregnancy (aOR 2.58, 95%CI 1.37-4.85); and obstetric complications (aOR 4.04, 95%CI 2.35-6.94). For intrapartum stillbirths, associated factors were preterm birth (aOR 11.28, 95%CI 4.66-27.24); referral (aOR 2.50, 95%CI 1.19-5.24); not using a partogram (aOR 2.92, 95%CI 1.23-6.95) and obstetric complications (aOR 10.71, 95%CI 5.92-19.37). The findings highlight specific risk factors associated with antepartum and intrapartum stillbirths, shedding light on potential areas for targeted interventions.

The burden of stillbirths in low resource settings in Latin America: Evidence from a network using an electronic surveillance system.

To determine stillbirth ratio and its association with maternal, perinatal, and delivery characteristics, as well as geographic differences in Latin American countries (LAC). We analysed data from the Perinatal Information System of the Latin American Center for Perinatology and Human Development (CLAP) between January 2018 and June 2021 in 8 health facilities from five LAC countries (Bolivia, Guatemala, Honduras, Nicaragua, and the Dominican Republic). Maternal, pregnancy, and delivery characteristics, in addition to pregnancy outcomes were reported. Estimates of association were tested using chi-square tests, and P < 0.05 was regarded as significant. Bivariate analysis was conducted to estimate stillbirth risk. Prevalence ratios (PR) with their 95% confidence intervals (CI) for each predictor were reported. In total, 101,852 childbirths comprised the SIP database. For this analysis, we included 99,712 childbirths. There were 762 stillbirths during the study period; the Stillbirth ratio of 7.7/1,000 live births (ranged from 3.8 to 18.2/1,000 live births across the different maternities); 586 (76.9%) were antepartum stillbirths, 150 (19.7%) were intrapartum stillbirths and 26 (3.4%) with an ignored time of death. Stillbirth was significantly associated with women with diabetes (PRadj 2.36; 95%CI [1.25-4.46]), preeclampsia (PRadj 2.01; 95%CI [1.26-3.19]), maternal age (PRadj 1.04; 95%CI [1.02-1.05]), any medical condition (PRadj 1.48; 95%CI [1.24-1.76, and severe maternal outcome (PRadj 3.27; 95%CI [3.27-11.66]). Pregnancy complications and maternal morbidity were significantly associated with stillbirths. The stillbirth ratios varied across the maternity hospitals, which highlights the importance for individual surveillance. Specialized antenatal and intrapartum care remains a priority, particularly for women who are at a higher risk of stillbirth.

Maternal interventions to decrease stillbirths and neonatal mortality in Tanzania: evidence from the 2017-18 cross-sectional Tanzania verbal and social autopsy study

BackgroundReduction of Tanzania’s neonatal mortality rate has lagged behind that for all under-fives, and perinatal mortality has remained stagnant over the past two decades. We conducted a national verbal and social autopsy (VASA) study to estimate the causes and social determinants of stillbirths and neonatal deaths with the aim of identifying relevant health care and social interventions.MethodsA VASA interview was conducted of all stillbirths and neonatal deaths in the prior 5 years identified by the 2015-16 Tanzania Demographic and Health Survey. We evaluated associations of maternal complications with antepartum and intrapartum stillbirth and leading causes of neonatal death; conducted descriptive analyses of antenatal (ANC) and delivery care and mothers’ careseeking for complications; and developed logistic regression models to examine factors associated with delivery place and mode.ResultsThere were 204 stillbirths, with 185 able to be classified as antepartum (88 [47.5%]) or intrapartum (97 [52.5%]), and 228 neonatal deaths. Women with an intrapartum stillbirth were 6.5% (adjusted odds ratio (aOR) = 1.065, 95% confidence interval (CI) 1.002, 1.132) more likely to have a C-section for every additional hour before delivery after reaching the birth attendant. Antepartum hemorrhage (APH), maternal anemia, and premature rupture of membranes (PROM) were significantly positively associated with early neonatal mortality due to preterm delivery, intrapartum-related events and serious infection, respectively. While half to two-thirds of mothers made four or more ANC visits (ANC4+), a third or fewer received quality ANC (Q-ANC). Women with a complication were more likely to deliver at hospital only if they received Q-ANC (neonates: aOR = 4.5, 95% CI 1.6, 12.3) or ANC4+ (stillbirths: aOR = 11.8, 95% CI 3.6, 38.0). Nevertheless, urban residence was the strongest predictor of hospital delivery.ConclusionsWhile Q-ANC and ANC4 + boosted hospital delivery among women with a complication, attendance was low and the quality of care is critical. Quality improvement efforts in urban and rural areas should focus on early detection and management of APH, maternal anemia, PROM, and prolonged labor, and on newborn resuscitation.

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.

Burden, Differentials and Causes of Stillbirths in India: A Systematic Review and Meta Analysis.

India contributes the highest absolute number of stillbirths in the world. This systematic review and meta-analysis was conducted to synthesize the burden, timing and causes of stillbirths in India. Forty-nine reports from 46 studies conducted in 21 Indian states and Union Territories were included. It was found that there was no uniformity/standardization in the definition of stillbirths and in the classification system used to assign the cause. The share of antepartum stillbirths was estimated to betwo-third while remaining were intrapartum stillbirths. Maternal conditions and fetal causes were found to bethe leading cause of stillbirth in India. The maternal condition was assigned as the commonest cause (25%) followed by fetal (14%), placental cause (13%), congenital malformation (6%) and intrapartum complications (4%). Approximately 20% of the stillbirths were assigned asunknown or unexplained. This review demonstrates that there is a paucity of quality stillbirth data in India. Other than thestate level differences in stillbirth rates, no other data is available on inequities in stillbirths in India. There is an urgent need for strengthening availability and quality of stillbirth data in India on both stillbirth rates as well as thecauses. There is a need to conduct additional research to know the timing of thestillbirths, causes of death and actual burden. India needs to strengthen stillbirth audits along with registry to find out the modifiable factors and delays for making country specific preventive strategies. The policy makers, academic community and researchers need to work together to ensure accelerated and equitable reduction in stillbirths in India.