Factors associated with stillbirth in selected countries of South Asia: A systematic review of observational studies

Maternal age and adverse pregnancy outcomes among Meitei women of Manipur, Northeast India: A cross-sectional study

OBJECTIVE

The study examines the outcomes of pregnancies conceived at advanced maternal age (AMA) and maternal complications after childbirth among Meitei women of Northeast India.

METHOD

A total of 760 women participants were included in this study and compared among women aged ≥35 years, with a reference group of women aged 20-34 years. Data on obstetric characteristics were collected after obtaining consent. The data were compared using chi-square analysis, and the results were adjusted using a logistic regression model. Decision trees were developed to predict the potential variables associated with preterm delivery and postpartum complication.

RESULTS

In the study, 18.95% of AMA women experienced one or more adverse pregnancy outcomes (APOs). Women with AMA are at significantly increased risk of placenta previa (adjusted odds ratio [AOR] = 4.89, 95% confidence interval [CI]: 2.78-8.57), induction of labor (AOR = 3.69, 95%CI: 2.48-5.50), and caesarean section (AOR = 3.42, 95%CI: 2.28-5.12). Moreover, AMA women have a 1.86-2.76 AOR for developing gestational diabetes, pregnancy-induced hypertension, urinary tract infections, preterm delivery, and postpartum complications. Decision tree analysis revealed that AMA and urban residence independently predict preterm delivery and postpartum complications.

CONCLUSION

The study's findings confirm the adverse impact of AMA on pregnancy outcomes and postpartum complications. Such issues should be addressed, and counseling on the risk of AMA should be provided, particularly for those in the high-risk group. Further prospective studies are needed to understand other potential risk factors of APOs and the impact of AMA complications to prevent the associated burden.

Determinants of stillbirths in sub-Saharan Africa: A systematic review

BACKGROUND

Sub-Saharan African (SSA) countries have high stillbirth rates compared with high-income countries, yet research on risk factors for stillbirth in SSA remain scant.

OBJECTIVES

To identify the modifiable risk factors of stillbirths in SSA and investigate their strength of association using a systematic review.

SEARCH STRATEGY

CINAHL Plus, EMBASE, Global Health and MEDLINE databases were searched for literature.

SELECTION CRITERIA

Observational population- and facility-level studies exploring stillbirth risk factors, published in 2013-2019 were included.

DATA COLLECTION AND ANALYSIS

A narrative synthesis of data was undertaken and the potential risk factors were classified into subgroups.

MAIN RESULTS

Thirty-seven studies were included, encompassing 20 264 stillbirths. The risk factors were categorised as: maternal antepartum factors (0-4 antenatal care visits, multiple gestations, hypertension, birth interval of >3 years, history of perinatal death); socio-economic factors (maternal lower wealth index and basic education, advanced maternal age, grand multiparity of ≥5); intrapartum factors (direct obstetric complication); fetal factors (low birthweight and gestational age of <37 weeks) and health systems factors (poor quality of antenatal care, emergency referrals, ill-equipped facility). The proportion of unexplained stillbirths remained very high. No association was found between stillbirths and body mass index, diabetes, distance from the facility or HIV.

CONCLUSIONS

The overall quality of evidence was low, as many studies were facility based and did not adjust for confounding factors. This review identified preventable risk factors for stillbirth. Focused programmatic strategies to improve antenatal care, emergency obstetric care, maternal perinatal education, referral and outreach systems, and birth attendant training should be developed. More population-based, high-quality research is needed.

Influencing factors associated with maternal delivery at home in urban areas: a cross-sectional analysis of the Bangladesh Demographic and Health Survey 2017-2018 data

BACKGROUND

The associated factors and patterns of giving birth in home settings of rural areas have been extensively studied in Bangladeshi literature. However, urban areas still need to be explored, particularly with recent data. Therefore, the authors aimed to investigate the influential determinants of delivery at home in urban areas of Bangladesh.

MATERIALS AND METHODS

In this study, 1699 urban-dwelling women who had given birth within the previous 60 months of the survey and lived in urban areas were used. The secondary data were extracted from the latest Bangladesh Demographic and Health Survey 2017-2018. Descriptive statistics and logistic regression were applied along with the association among selected variables were examined by the Chi-square test.

RESULTS

Findings depict that 36.49% of women who lived in urban areas of Bangladesh delivered at home, whereas, 63.51% delivered at different govt. and private health care facilities. Women who lived in Chittagong [adjusted odds ratio (AOR) = 2.11, 95% CI 1.24-3.60], Barisal [AOR = 2.05, 95% CI 1.16-3.64] and Sylhet [AOR = 1.92, 95% CI 1.08-3.43] divisions have more likelihood to deliver at home (36.85%). Urban women following Christian religion [AOR = 10.71, 95% CI 1.32-86.68] have higher odds of delivering child at home (0.47%). Urban women having three or more children before her latest delivery (22.37%) and who are employed (29.37%) have more likelihood to deliver at home. However, women aged between 25 and 34 years (43.50%), who have higher education (25.90%), play the role of household head (9.06%), have parity of more than two births (2.24%), and read daily newspapers (68.69%) had a lower chance of delivery at home. Furthermore, women from wealthier families (89.12%) and more antenatal care (ANC) visits (94.93%) were less likely to have a delivery at home.

CONCLUSION

Despite significant progress in women and reproductive health in Bangladesh, the proportion of delivery in the home in urban areas is alarming and should be emphasized more. The authors believe the identified factors will help design interventions and policy development on this issue.

Socioeconomic and geographical inequalities in health care coverage in Mozambique: a repeated cross-sectional study of the 2015 and 2018 national surveys

BACKGROUND

Over the past years, Mozambique has implemented several initiatives to ensure equitable coverage to health care services. While there have been some achievements in health care coverage at the population level, the effects of these initiatives on social inequalities have not been analysed.

OBJECTIVE

The present study aimed to assess changes in socioeconomic and geographical inequalities (education, wealth, region, place of residence) in health care coverage between 2015 and 2018 in Mozambique.

METHODS

The study was based on repeated cross-sectional surveys from nationally representative samples: the Survey of Indicators on Immunisation, Malaria and HIV/AIDS in Mozambique (IMASIDA) 2015 and the 2018 Malaria Indicator survey. Data from women of reproductive age (15 to 49 years) were analysed to evaluate health care coverage of three indicators: insecticide-treated net use, fever treatment of children, and use of Fansidar malaria prophylaxis for pregnant women. Absolute risk differences and the slope index of inequality (SII) were calculated for the 2015 survey period and the 2018 survey period, respectively. An interaction term between the socioeconomic and geographical variables and the period was included to assess inequality changes between 2015 and 2018.

RESULTS

The non-use of insecticide-treated nets dropped, whereas the proportion of women with children who were not treated for fever and the prevalence of women who did not take the full Fansidar dose during pregnancy decreased between 2015 and 2018. Significant reductions in the inequality related to insecticide-treated net use were observed for all socioeconomic variables. Concerning fever treatment, some reductions in socioeconomic inequalities were observed, though not statistically significant. For malaria prophylaxis, the SII was significant for education, wealth, and residence in both periods, but no significant inequality reductions were observed in any of these variables over time.

CONCLUSIONS

We observed significant reductions of socioeconomic inequalities in insecticide-treated net use, but not in fever treatment of children and Fansidar prophylaxis for pregnant women. Decision-makers should target underserved populations, specifically the non-educated, poor, and rural women, to address inequalities in health care coverage.

Trends and risk factors of stillbirth among women of reproductive age in Pakistan: A multivariate decomposition analysis

Background

Every year, 2 million babies are stillborn in the world. Globally, there has been a decline in the stillbirth rate of 2%. Despite advancements in prenatal care and the implementation of new medical technologies, the incidence of early stillbirths remains unchanged. A slight decrease in the rate of late-term stillbirth has been observed. Pakistan ranked third in South Asia for having the highest stillbirth rate. Compared to its neighbors and other developing nations, Pakistan has shown a lack of progress in reducing maternal and neonatal fatalities. Therefore, the purpose of this study is to use a multivariate decomposition analysis to examine the trends and factors that have contributed to the change in the stillbirth rate over time.

Methods

To conduct this study, we used a secondary data analysis approach and analyzed data from the Pakistan Demographic and Health Survey (PDHS) of 2012-2013 and 2017-2018). For the analysis, a total sample of 15,068 births in 2017-2018 and 13,558 births in the PDHS from 2012 to 2013 were taken into account. Using the MVDCMP function within STATA version 15 statistical software, a logit-based multivariate decomposition model was fitted to determine the variables that influence the change in stillbirth. The current study used two cross-sectional surveys to identify important risk factors for stillbirths.

Results

Over the past 5 years, Pakistan's stillbirth rate has risen from 3.98 to 5.75%. According to the total multivariate decomposition analysis, the change in coefficient (change in the effect of attributes) accounted for 81.17% of the overall change in the proportion of stillbirths. In contrast, the change in endowment was not statistically significant. Changes in maternal education, individual and community-level wealth status, and mode of delivery all significantly impacted the rate of stillbirths over time.

Conclusion

Stillbirths increased in Pakistan from 2012 to 2017. Stillbirths are observed more frequently for women residing in Punjab, Sindh, and rural areas. A major concern that is directly related to the prevalence of stillbirths in Pakistan is the lack of accessible, affordable, and high-quality maternal healthcare facilities. Older, overweight, and uneducated women are more likely to have stillbirths than women who deliver vaginally. High parity and short birth intervals also accelerated the rate of stillbirths. An effective remedy to control stillbirths is the provision of accessible and affordable healthcare services. Awareness campaigns for the health education of pregnant women should focus on raising awareness to support better pregnancy outcomes for poor women living in communities with higher education levels. The risk of stillbirth can be reduced by offering free diagnostics for early detection of birth complications in low-resource settings and referring these cases to knowledgeable gynecologists for safe delivery.

Measurement and mapping of maternal health service coverage through a novel composite index: a sub-national level analysis in India

BACKGROUND

Expansion of maternal health service coverage is crucial for the survival and wellbeing of both mother and child. To date, limited literature exists on the measurement of maternal health service coverage at the sub-national level in India. The prime objectives of the study were to comprehensively measure the maternal health service coverage by generating a composite index, map India by categorizing it into low, medium and high zones and examine its incremental changes over time.

METHODS

Utilising a nationally representative time series data of 15 key indicators spread across three domains of antenatal care, intranatal care and postnatal care, we constructed a novel 'Maternal Health Service Coverage Index' (MHSI) for 29 states and 5 union territories of India for the base (2017-18) and reference (2019-20) years. Following a rigorous procedure, MHSI scores were generated using both arithmetic mean and geometric mean approaches. We categorized India into low, medium and high maternal health service coverage zones and further generated geospatial maps to examine the extent and transition of maternal health service coverage from base to reference year.

RESULTS

India registered the highest mean percentage coverage (93.7%) for 'institutional delivery' and the lowest for 'treatment for obstetric complications' (9.3%) among all the indicators. Depending on the usage of arithmetic mean and geometric mean approaches, the maternal health service coverage index score for India exhibited marginal incremental change (between 0.015-0.019 index points) in the reference year. West zone exhibited an upward transition in the coverage of maternal health service indicators, while none of the zones recorded a downward movement. The states of Mizoram (east zone) and the Union Territory of Puducherry (south zone) showed a downward transition. Union territories of Dadra & Nagar Haveli (west zone) and Chandigarh (north zone), along with the states of Maharashtra (west zone), Assam, as well as Jharkhand (both from the east & north east zone), showed upward transition.

CONCLUSION

Overall, maternal health service coverage is increasing across India. Our study offers a novel summary measure to comprehensively quantify the coverage of maternal health services, which can momentously help India identify lagged indicators and low performing regions, thereby warranting the targeted interventions and concentrated programmatic efforts to bolster the maternal health service coverage at the sub-national level.

Stillbirths among Pregnant Women Admitted to Department of Obstetrics in a Tertiary Care Centre: A Descriptive Cross-sectional Study

INTRODUCTION

Stillbirth is often defined as the death of a foetus in the uterus prior to its birth or during the process of birth. Most of the stillbirths are preventable global health problem. The aim of this study was to find out the prevalence of stillbirths among pregnant women admitted to the Department of Obstetrics and Gynaecology in a tertiary care centre.

METHODS

A descriptive cross-sectional study was conducted in the Department of Obstetrics and Gynaecology of a tertiary care centre among pregnant women admitted between 14 April 2021 to 13 April 2022. Ethical approval was taken from the Institutional Review Committee (Reference number: 43). Convenience sampling method was used. The data was collected from the medical record section using a proforma. Point estimate and 95% Confidence Interval were calculated.

RESULTS

Among 5118 pregnant women, stillbirths were found in 126 (2.46%) (2.04-2.88, 95% Confidence Interval).

CONCLUSIONS

The prevalence of stillbirth among pregnant women was higher than in the other studies done in similar settings.

The effect of inter-pregnancy interval on stillbirth in urban South Ethiopia: a community-based prospective cohort study

BACKGROUND

Stillbirth is an invisible and poorly understood adverse pregnancy outcome that remains a challenge in clinical practice in low-resource settings. It is also a key concern in Ethiopia where more than half of pregnancies occur shortly after preceding childbirth. Whether the interval between pregnancies has an effect on stillbirth or not is unclear. Therefore, we aimed to assess the effect of inter-pregnancy interval on stillbirth in urban South Ethiopia.

METHODS

A community-based prospective cohort study was conducted among 2578 pregnant women and followed until delivery. Baseline data were collected at the household level during registration and enrolment. End-line data were collected from hospitals during delivery. Exposed groups were pregnant women with inter-pregnancy intervals < 18 months and 18-23 months. Unexposed group contains women with inter-pregnancy intervals 24-60 months. A generalized linear model for binary outcome was applied, using R version 4.0.5 software. Relative risk (RR) was used to estimate the effect size with a 95% confidence level. Attributable fraction (AF) and population attributable fraction (PAF) were used to report the public health impact of exposure.

RESULTS

The overall incidence of stillbirth was 15 per 1000 total births, (95% CI: 11, 20%). However, the incidence was varied across months of inter-pregnancy intervals; 30 (< 18 months), 8 (18-23 months) and 10 (24-60 months) per 1000 total births. The risk of stillbirth was nearly four times (ARR = 3.55, 95%CI: 1.64, 7.68) higher for women with inter-pregnancy interval < 18 months as compared to 24-60 months. This means, about 72% (AF = 72, 95%CI: 39, 87%) of stillbirth among the exposed group (inter-pregnancy interval < 18 months category) and 42% (PAF = 42, 95%CI: 23, 50%) of stillbirth in the study population were attributed to inter-pregnancy interval < 18 months. These could be prevented with an inter-pregnancy interval that is at least 18 months or longer.

CONCLUSIONS

Inter-pregnancy interval under 18 months increases the risk of stillbirth in this population in urban South Ethiopia. Interventions targeting factors contributing to short inter-pregnancy intervals could help in reducing the risk of stillbirth. Improving contraceptive utilization in the community could be one of these interventions.

Gestational diabetes mellitus (GDM) and adverse pregnancy outcome in South Asia: A systematic review

INTRODUCTION

The prevalence of gestational diabetes mellitus (GDM) is increasing in developing countries including the South Asian Nations. The current study aimed to examine the association of GDM with adverse pregnancy outcomes from foetal and maternal perspectives in South Asia.

METHODS

A systematic review was conducted including primary studies published since January 2020 from South Asian countries. Following electronic databases were searched to locate the articles: MEDLINE, EMBASE and EMCARE. Data were extracted using a customized extraction tool and methodological quality of the included studies was assessed using modified Effective Public Health Practice Project (EPHPP) quality assessment tool. Narrative synthesis was performed as statistical pooling was not possible due to the heterogeneous nature of the studies.

RESULTS

Eight studies were included in the review. Overall, the review found a positive correlation between GDM and adverse foetal outcomes such as macrosomia, neonatal hyperglycaemia, intrauterine growth retardation (IUGR), stillbirths and low birthweight (LBW), but the findings were not conclusive. GDM was also positively associated with preeclampsia but the association between GDM and C-section delivery was not conclusive.

CONCLUSION

Policymakers, public health practitioners and researchers in South Asia should take in to account the link between GDM and adverse pregnancy outcomes while designing interventions to promote maternal health in South Asia. Researchers should focus on conducting longitudinal studies in future to clearly understand the epidemiology and pathobiology of this issue.