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 Table of Contents  
Year : 2018  |  Volume : 25  |  Issue : 2  |  Page : 87-93

Tracking stillbirths by referral pattern and causes in a rural tertiary hospital in Southern Nigeria

1 Department of Obstetrics and Gynaecology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra, Nigeria
2 Department of Paediatrics, Federal Medical Centre, Owerri, Nigeria
3 Department of Paediatrics, Madonna University Teaching Hospital, Rivers State, Nigeria
4 Department of Obstetrics and Gynaecology, Madonna University Teaching Hospital, Rivers State, Nigeria

Date of Web Publication19-Jul-2018

Correspondence Address:
Ikechukwu Innocent Mbachu
Department of Obstetrics and Gynecology, Nnamdi Azikiwe University, Nnewi Campus, PMB 5025, Nnewi, Anambra State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/npmj.npmj_73_18

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Background: The burden of stillbirth is disproportionately more in rural areas of developing countries where unskilled birth attendants contribute a large quota in the management of pregnant women. Tracking stillbirth should include the pattern of referral from the primary institutions that take care of these women. Aims and Objectives: This study evaluated the causes and determinants of stillbirth by the referral pattern in a rural area in southern Nigeria. Subjects and Methods: This was a retrospective case–controlled study of stillbirth at the Madonna University Teaching Hospital, Elele, from 2010 to 2014. The lying-in, delivery and theatre registers were used to extract the relevant information. For each stillbirth, two controls were selected which were live births. Data analysis was performed using SPSS version 20. The confidence interval was 95% set at value of P = 0.05. Result: During the study, a total of 1243 neonates were delivered at the hospital, the number of live births and stillbirths were 1025 and 218, respectively. This gives a stillbirth rate of 175/1000 deliveries. Only 179 neonates whose case files were retrieved were used in the analysis. There were 87 fresh and 92 macerated stillbirths. Intrapartum complications contributed 91 (51.40%) of the stillbirths with traditional birth attendants and maternity homes contributing 72%. Determinants include booking status, educational level, abruptio placentae, preeclampsia, ruptured uterus, prolonged labor and low birthweight. Conclusion: The study showed an unacceptably high rate of stillbirth in rural Nigeria. Early recognition of complications and prompt referral may reduce stillbirth rate.

Keywords: Causes, determinants, rural area, primary institutions, stillbirths

How to cite this article:
Mbachu II, Achigbu KI, Odinaka KK, Eleje GU, Osuagwu IK, Osim VO. Tracking stillbirths by referral pattern and causes in a rural tertiary hospital in Southern Nigeria. Niger Postgrad Med J 2018;25:87-93

How to cite this URL:
Mbachu II, Achigbu KI, Odinaka KK, Eleje GU, Osuagwu IK, Osim VO. Tracking stillbirths by referral pattern and causes in a rural tertiary hospital in Southern Nigeria. Niger Postgrad Med J [serial online] 2018 [cited 2022 Nov 29];25:87-93. Available from: https://www.npmj.org/text.asp?2018/25/2/87/237090

  Introduction Top

The expectant joy and dreams of delivery of live neonates by pregnant women are often aborted by the death of the fetus before delivery. This is more evident in developing countries with a high premium on childbearing and may be complicated by other medical and obstetric conditions which may affect future childbearing and health of the women. Globally, it is estimated that 2.6 million third trimester stillbirths occur annually, 7300 occur every day, and 98% of them occur in low- and medium-income countries.[1],[2] The stillbirth rate varies from the country-to-country and region-to-region in the same country. The national average for Finland is 2/1000 deliveries.[3] It is 42/1000 in Nigeria with wide regional variations between 6.1 and 180/1000 deliveries.[4],[5],[6],[7],[8]

One of the challenges in the study of stillbirth is the dearth of data in developing countries. National values are usually estimates and are not a reliable tool for planning and implementation of strategies, especially in developing countries. Hospital-based studies have continued to provide useful information on stillbirth despite the obvious shortcomings.[5],[6] Another challenge is that most studies in developing countries on stillbirth are mainly in urban areas which may not give the actual disease burden considering the differences in patients' characteristics and available medical services.[6],[7] It is estimated that 57% of stillbirths occur in rural areas of the developing countries.[4]

Many factors contribute to the high burden of stillbirths, especially in rural areas of developing countries. These include patient, workforce and health institution's factors. The proportions of women who access antenatal care are suboptimal. Studies have shown that only about 24% of doctors and 38% of nurses work in rural areas of the world that contribute half of the world's population.[9] The implication of the low percentage of skilled birth attendants is that most deliveries will be conducted by unskilled birth attendants who may not have the necessary training and skills to manage the complications that may arise during labour. The high percentage of unskilled birth attendants should be considered in any long-term strategy aimed at reduction of stillbirth and maternal mortality. Identifying the characteristics of women who have stillbirth, where they primarily receive care, when they occur and why they occur will help in policy formulation geared towards reduction of stillbirth. It may also reveal the gaps in the quality of maternal services, associated medical conditions, socioeconomic, cultural and institutional factors closely related to maternal and perinatal morbidity and mortalities.

Different factors are considered in the classification of stillbirths include the timing with respect to the period of pregnancy, medical causes and finding at autopsy. Some of the classifications included were as follows Aberdeen, Wigglesworth, Baid and Pattison. However, most of them are too complex to be used in developing countries.[4] The high rate of non-acceptability of autopsy in the developing countries has hindered the identification of the causes of stillbirth.[10] Some studies in developing countries had used verbal autopsy in the identification of stillbirth.[10] Others have used clinical methods such as Baird-Pattison classification in the identification of the causes of stillbirth.[11] The latter was used to identify the causes of stillbirth in this study. This study evaluated the rate, referral pattern, causes, timing and determinants of stillbirth in a rural referral hospital in Niger Delta region of Nigeria.

  Subjects and Methods Top

Study design

This was a case–controlled retrospective study of stillbirth in Madonna University Teaching Hospital Elele in Southern Nigeria from January 2010 to December 2014.

Ethical approval was obtained from College of Madonna University ethical committee (reference number PO/COM/MAU/001 on 16/02/2016) before the commencement of the study.

Study area

The study was carried out in the Obstetrics and Gynaecology Department of the Madonna University Teaching Hospital, Elele, River State in Nigeria. Madonna University Teaching Hospital offers antenatal, intrapartum, postnatal and other reproductive health services to all women who present to the hospital.


The lying-in, delivery and theatre registers were used to extract the names and hospital numbers of women that had stillbirth over the study. The case files were then retrieved after obtaining Institutional Review Board approval. The relevant information which included the age, parity, educational status, religion, booking status, occupation and referring institutions were retrieved. Other information retrieved included maternal medical and obstetrics complications, period of diagnosis and type of stillbirth (whether fresh or macerated), evaluation of the causes of foetal demise using the clinico-pathological system designed by Baird-Pattinson and mode of delivery. We included all cases of births without evidence of life after 28 weeks and or weight of 1000 g and above. For each stillbirth, two controls were selected which were consecutive live births, delivered after the stillbirth. The relevant information which included sociodemographic, medical and obstetrics complications and mode of delivery were extracted from the case files. Missing information was designated as missing value and tabulated for both live births and stillbirths.

Data analysis

Data analysis was performed using SPSS Statistical package for social sciences version 20, (IBM, Armonk, NY, USA). Descriptive statistics was used to generate frequencies, mean and tables. There was cross tabulation to explore relationship between selected variables. Logistic regressions were used to predict the determinants of stillbirth using odd ratio. The confidence interval was 95% set at value of P ≤ 0.05.

  Results Top

During the study, a total of 1243 babies were delivered in the hospital (1243). The number of live births was 1025 babies (1025) while a total of 218 stillbirths were recorded. This gives a stillbirth rate of 175/1000 (deliveries). Only 179 out of the 218 (82.57%) case files of women with stillbirths were retrieved while only 348 (80.48%) of the 420 folders of women with live births were retrieved. The distribution of the stillbirths showed that 87/179 (48.60%) were fresh stillbirths while 92/179 (51.4%) were macerated stillbirths. The fresh stillbirths occurred in 30/87 (34.40%) of the patients that booked at the hospital while 57/87 (65.51%) occurred in patients that were not booked in the hospital. Unbooked patients accounted for 82/91 (89.01%) 0f the macerated stillbirths.

[Table 1] shows the distribution of the causes of stillbirth (Baird-Pattison classification) according to the referring institutions. Intrapartum problems contributed 91/179 (50.84%) of the stillbirth. Patients referred from maternity homes and traditional births attendants contributed 27/179 (27.67%) and 39 (42.86%) of the intrapartum-related stillbirths, respectively. Twenty-two (12.29%) of the stillbirths were as a result of hypertensive disorders of pregnancy. Women who had stillbirth were more likely to be unbooked at the centre with significant odd ratio and a P< 0.00. Furthermore, women who had stillbirths had significantly odd ratio of being grandimultiparous odd ratio of 2.32, 95% confidence interval of 1.32–4.07 and a P < 0.00. Age did not significantly predict stillbirths in this study. [Table 2] shows the socioeconomic determinants of stillbirth with the odd ratios and 95% confidence interval.
Table 1: Causes of stillbirth (Baird-Pattinson classification of causes of fetal death,) according to referring institution

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Table 2: Sociodemographic determinants

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Maternal medical and obstetrics co-morbid determinant include anaemia and febrile illness while obstetrics determinants include preeclampsia, multiple gestation and abruptio placenta. Among patients with stillbirths, 33/179 (18.44%) had anaemia while 28/348 (8.05) of the patients with live births had anaemia. Multiple gestation was noted in 19/179 (10.61%) of the stillbirth and 11/348 (3.16%) in women with livebirths while abruptio placenta occurred15/179 (8.38%) of the stillbirth group and in 4/348 (1.15%) of the live births. The maternal medical and obstetrics determinants of stillbirth are shown in [Table 3].
Table 3: Maternal medical and obstetrics morbidities determinants

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The presence of obstructed labour and uterine rupture predicts high rate of stillbirth. Obstructed labour was documented in 63/179 (35.25) of the women with stillbirth and 40/348 (11.49%) in those with livebirths. A total of 14/179 cases of uterine rupture were documented in women with uterine rupture while none was recorded for women with livebirths. Prolonged rupture of membrane >24 h significantly predicted stillbirth 86/179 (48.04%) in stillbirth group compared to 59/3489 (16.95%) in the live birth group. Pronged labour >24 h was also significantly associated stillbirths. The intrapartum determinants of stillbirth are in shown in [Table 4]. [Table 5] shows the foetal determinants of stillbirths. The foetal determinants include birth weight <1.5 kg and >4 kg. Gestational age <34 weeks and >42 weeks were significant predictors of stillbirths.
Table 4: Intrapartum determinants

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Table 5: Fetal determinants

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  Discussion Top

The stillbirth rate of 175/1000 births recorded in this study is far above the national average of 42/1000 deliveries.[3] This implies that for every five families that achieved pregnancy and carried it to the age of viability, one family's joy was replaced with grief of loss of the foetus. Some may never conceive again due to the associated complications that may affect future childbearing. This represents the fate and stories of many families in rural areas of developing countries. It is higher than values recorded in other studies in Urban Nigeria (30.5/1000 in Jos, 33/1000 in Ado-Ekiti) and other Sub-Saharan Africa Cities,[6],[12],[13] and far higher than values obtained in developed countries.[3] This very high value reported in this study is comparable to 180/1000 deliveries reported from rural northern Nigeria.[14]

The unacceptable prevalence is partly as a result of preventable intrapartum complications which accounted for more than 50% of the stillbirths. Two studies have shown that intrapartum complications account for about 50% of stillbirths in developing countries.[15],[16] The high rate of intrapartum-related stillbirth was partly due to delayed recognition and late referral of complicated labour cases to the study hospital which is the major referral centre in the rural setting of the study site. Lack of access to antenatal care and emergency obstetrics care services and dearth of skilled birth attendants are well-recognised causes of high rate of stillbirth in developing countries.[9]

The analysis showed that most women that had intrapartum complications were referred from traditional birth attendants and maternity homes which accounted for more than 72% of the intrapartum-related stillbirth. This is probably because they do not have the minimum training to recognise problems early enough for prompt referral. In addition, cultural prejudices which regard women who have assisted deliveries as weaklings tend to encourage the high patronage of triditional birth attendants (TBAs) and maternities to avoid operative delivery even for anticipated complicated delivery. This brings to the fore, the need for partnering with them through education on the early recognition and prompt referral of complicated pregnancies. Thus, TBAs and other unskilled birth attendants are usually the first point of call by pregnant women and represent a potential target for reduction of stillbirth rate. Some studies had emphasised on the need for task sharing and task shifting in rural areas that bear the highest burden of maternal and perinatal mortality as an approach for reduction of maternal and perinatal mortality in rural areas based on their peculiarities.[17],[18]

The proportion of macerated stillbirth is higher than fresh stillbirth in this study. Other studies in Nigeria had shown that fresh stillbirths which correlate with intrapartum complications are commoner.[6],[7] The high rate of macerated stillbirth means that the stillbirths occurred more than 24 h before delivery. It is generally believed that it represents stillbirths in antepartum period. This may be due to referral pattern of such cases, since women were referred late when foetal revival may be impossible. Thus, in rural settings, women labour for days even in the presence of stillbirth and other complications of labour as was shown in this study.

Maternal age was not significantly associated with stillbirth in this study. This is in contrast to previous findings in Jos, Nigeria by Mutihir et al. where maternal age was significantly associated with stillbirth.[6] Parity >4 was noted to increase the risk of stillbirths in this study. This has been observed in several studies.[19],[20] The reasons for this observation include the characteristics of grandmultipraous women which include no antenatal care, unsupervised vaginal delivery, and advanced maternal age. There was no significant association with age 20 years and below which may be explained by few number of women below the age of 20 years in this study. This is in contrast to studies in northern Nigeria that have revealed association with stillbirth.[6] The difference may be explained by early marriage and childbirth which are common in northern Nigeria due to culture and religion.[6],[14]

Women with tertiary education were more likely to book for antenatal care. This is also reflected in the stillbirth rate which was high in unbooked patients. This relationship between stillbirth and booking status has been observed in other studies.[5],[6],[7] The reason may be because women who attend antenatal care are more likely to benefit from screening and early detection of conditions such as preeclampsia and supervised delivery by a skilled birth attendant. There was a significant relationship between preeclampsia and stillbirth consistent with other studies.[6],[7] Febrile illness and anaemia were found to significantly increase the risk of stillbirth. Patients who had febrille illness before delivery had a higher rate of stillbirths. Febrile illness may result from infection-related stillbirths and has association with prolonged labour and prolonged rupture of membrane. There was strong correlation between stillbirth and abruptio placentae, uterine rupture and stillbirth which agrees with findings in other studies.[5],[6] However, some studies in developed countries have shown low perinatal mortality, which is a strong indication of intrapartum care and response to emergencies.[1],[4],[21]

The association between stillbirth and maternal diabetes mellitus was not significant and was partly due to few cases documented in this study. The strong association between stillbirths, low birth weight and foetal macrosomia in this study had been documented in other studies.[22],[23],[24] The insignificant relationship of stillbirth with congenital anomalies may be closely related to the few number of cases recorded in this study. Pregnancies below 34 weeks and above 42 weeks were associated with high numbers of stillbirths. This may be related to deaths from complications of prematurity in preterm babies and reduced placenta function in post-term pregnancies. Many studies in developing countries have documented strong relationship between booking status and stillbirth, but very few have identified the levels of referring health institutions and pattern of stillbirth for the purpose of planning and tackling the disease burden.[4],[5],[6]

One of the strengths of our study was stratifying the causes of stillbirth according to referring institutions. This has led to identification of specific gaps and possible solutions from various health institutions. This is very important for referral hospitals in rural settings that handles mainly referred cases. The study had some limitations. The retrospective nature of the study did not allow for immediate follow-up of these institutions and could not confirm whether the maternities and traditional birth attendants have any formal training in obstetrics. In addition, autopsy was not done routinely for stillbirths due to the aversion and cost of autopsies in the study environment. Enactment of enabling laws will help to overcome this problem. Finally, this was a hospital-based study with low delivery rate which may overestimate the true prevalence in the study setting. However, using the 10% overestimation proposed by the WHO, this would still have given a prevalence that is still far higher than the national average of 42/1000 deliveries.

  Recommendations and Conclusion Top

This study has revealed the unacceptable high burden of stillbirth in rural settings in riverine area of southern Nigeria. It also showed the double risk of labour complications to mothers and their babies as evidenced by the high level of intrapartum-related stillbirths. It confirms the known fact that most deliveries in rural areas are not supervised by skilled birth attendants. This confirms the need for collaboration between the hospitals in rural areas that offer comprehensive emergency obstetrics care and the traditional birth attendants and other institutions where women seek help during pregnancy. There is urgent need to provide accessible, acceptable and affordable maternity services in rural areas.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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