Abstract:
Background:
Stillbirth 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.
Methods:
We 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.
Results:
From 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%).
Conclusions:
Stillbirth 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