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ORIGINAL ARTICLE
Year : 2022  |  Volume : 66  |  Issue : 1  |  Page : 15-19  

A critical assessment of stillbirths at a tertiary care hospital


1 Associate Professor, Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
2 Director Professor and Head, Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
3 Senior Resident, Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India
4 Director Professor, Department of Obstetrics and Gynecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi, India

Date of Submission20-Nov-2020
Date of Acceptance20-Jan-2022
Date of Web Publication5-Apr-2022

Correspondence Address:
Vandana Mohan
Department of Obstetrics and Gynecology, Guru Teg Bahadur Hospital, Dilshad Garden, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_1364_20

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   Abstract 


Background: Globally in 2015, 2.6 million stillbirths occurred with estimated stillbirth rate (SBR) of 18.4/1000 births. India is the world capital of stillbirth accounting for 22.6% of world's stillbirths. Objectives: The objective of the study is to study the demographic profile of women experiencing stillbirth, to understand the risk factors for stillbirth in low resource settings, and to find the etiology of stillbirth so as to facilitate designing of a stillbirth prevention strategy. Methods: This was a cross-sectional observational study done at a tertiary care hospital of Delhi from June 2017 to December 2019. All babies delivered after 20 weeks of gestation showing no sign of life after birth were considered stillborn. Prestructured proforma was filled for each case and data were analyzed. Results: A total of 50,461 births took place during the study period, out of which 1824 were stillborn, making SBR of 36.15/1000 births of our institution. Most of the women belonged to age group 21–25 years and more than 50% of women were illiterate. Twenty-nine percent of women were completely unbooked, 48% were referred from other centers and 23% were registered at our hospital. Placental causes accounted for 22%, hypertension for 23%, and labor complications for 9% of cases while in 22% cases, cause could not be found. Conclusion: Stillbirth remains a neglected issue. A significant proportion of stillbirths are preventable by adequate antenatal care. Notification of stillbirths will give us the exact figures and realization of the seriousness of the problem which will help us work towards the solutions.

Keywords: Demography, fetal growth restriction, intrapartum, stillbirth


How to cite this article:
Aggarwal R, Suneja A, Mohan V, Guleria K. A critical assessment of stillbirths at a tertiary care hospital. Indian J Public Health 2022;66:15-9

How to cite this URL:
Aggarwal R, Suneja A, Mohan V, Guleria K. A critical assessment of stillbirths at a tertiary care hospital. Indian J Public Health [serial online] 2022 [cited 2022 May 29];66:15-9. Available from: https://www.ijph.in/text.asp?2022/66/1/15/342589




   Introduction Top


As defined by World Health Organization (WHO), a stillborn baby is one with no signs of life prior to complete expulsion or extraction from its mother.[1] Gestational age cut off varies from country to country with WHO considering it to be 20 completed weeks of gestation or weighing 500 g or more.[2],[3] However, for international comparison WHO recommends using cut off of gestational age of 28 weeks or birth weight of 1000 g.[1] Globally in 2015, 2.6 million stillbirths occurred with estimated stillbirth rate (SBR) of 18.4/1000 births.[4] Almost 98% of these stillbirths were from low-and middle-income countries (LMICs), of which 77.4% were from sub-Saharan Africa and southern Asia. India has the dubious distinction of being the world capital of stillbirth accounting for the highest number of stillbirths, i.e., 592,000 (22.6% of world's stillbirths).[5]

Stillbirth has a traumatic effect on the life of a woman and her family. Reduction of stillbirths was neither considered as one of the Millennium Development Goals and nor as a Sustainable Development Goal. Between 2000–2015, there has been a global annual reduction in SBR of only 2% as compared to the annual reduction of 3% in maternal mortality rate and 4.5% in neonatal mortality rate during the same time period.[6] These findings suggest that SBR reduction has not been given its due importance by the WHO in 2014 Every Newborn Action Plan was launched to bring down the SBR to <12 per 1000 births by 2030.[7] The vision was to improve the coverage of care to the mother and her baby during childbirth and first few days after birth, in order to have a triple impact on investments in terms of mothers and neonates saved, as well as prevention of stillbirths.

Many risk factors have been associated with stillbirths. Strategies for reducing stillbirths require an analysis of etiology and risk factors as a first step. Several distal, intermediate, and proximal factors contribute to the high SBR in LMIC, and these tend to be related to one another. Potential distal factors include illiteracy among women, low socioeconomic status, and delay in seeking care. Intermediate factors may include young or advanced maternal age, lack of awareness about danger signs, poor maternal nutritional status, lack of awareness about danger signs and nonavailability of community resources. Lastly, maternal and fetal medical conditions and inadequately prepared medical facilities act as proximal risk factors for stillbirths.

Stillbirth evaluation has always been difficult due to various reasons such as nonavailability of services, religious and social beliefs, and financial limitations. It is observed that there are very large variations and inconsistencies across countries in the reporting of stillbirths. The aim of this study was to study the demographic profile of women experiencing stillbirth, to understand the risk factors for stillbirth in low resource settings, and to find the etiology of stillbirth so as to facilitate designing of a stillbirth prevention strategy.


   Materials and Methods Top


Stillbirth registry in India was started in July 2014 in collaboration with WHO-South-East Asian Region Office (WHO SEARO). Around 220 hospitals from 9 countries are currently registered as a part of the NBBD surveillance and 170 hospitals from 7 countries are reporting data on birth defects. Guru Teg Bahadur hospital is among the 9 hospitals in Delhi for collection of data on stillbirth, with Safdarjung hospital being the nodal center.

This was a cross-sectional observational study done at a tertiary care hospital of Delhi, from June 2017 to December 2019. As a part of the WHO SEARO project, a detailed evaluation of all stillbirths is done to find the etiology and is then reported at the WHO SEARO site. All babies delivered after 20 weeks of gestation showing no sign of life after birth were considered stillborn. Prestructured proforma was filled for each case. All antenatal records of the patients were reviewed, where available. Demographic profile of all the patients including age, education, booking status, parity, and period of gestation was noted. A detailed maternal history was taken with special consideration to the high-risk factors for stillbirths in the present and previous pregnancies. In the current pregnancy, history was taken for antepartum hemorrhage, abdominal trauma, preterm labor or rupture of membranes, cord accidents, fever, and cholestasis. Maternal history for diabetes, hypertension, thyroid disorders, anemia, heart disease, thromboembolism, smoking, alcohol intake, and drug use was elicited. A detailed general physical and systemic examination of the mother was done, and antenatal records were reviewed. All antenatal investigations were done including blood group, hemoglobin, serum thyroid-stimulating hormone, oral glucose tolerance test, viral markers (where required), and VDRL. Special investigations such as indirect Coombs test, antiphospholipid antibody test, TORCH IgM, liver and kidney function tests were done where appropriate. At birth, the baby was grossly examined and looked for the presence of maceration and gross congenital anomaly; weight and anthropometry done. Placenta and cord were examined in all cases and sent for histopathology when no cause for stillbirth was observed. Fetal autopsy was done where cause could not be found and consent for fetal autopsy was given by parents. Data were analyzed and all the categorical variables were reported as frequency (percentage) and continuous variables as mean (standard deviation).


   Results Top


During the study period from June 2017 to December 2019 (31 months), a total of 50,461 births took place at our institution, out of which 1824 were stillborn, making a SBR of 36.15 per 1000 births at our institution. The epidemiological profile of cases is given in [Table 1]. Maternal age ranged between 18 and 40 years; most of the women belonging to age group of 21–25 years (782/1824, 43%). Fifty-four percent of the women were illiterate. Of the 1824 stillbirths, 536 (29%) of mothers were completely unbooked and had received no antenatal care at all; 865 (48%) were referred to our hospital from other centers after the event of stillbirth had already occurred; and the rest 423 (23%) were booked/registered at our hospital. There were 563 (31%) nulliparous and 210 (12%) grand multiparous women. History of previous stillbirth was present in 118 women (6.5%) and previous abortions in 375 women (20.6%).
Table 1: Epidemiological profile of cases with stillbirth

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Fetal heartbeat was not present at the time of admission in 87.6% (1597/1824) cases. Over half of the stillbirths were macerated (58.3%) while the rest were fresh. In 62.6% of cases, stillbirth occurred after 32 weeks of gestation, which is the period of gestation beyond which babies can be usually saved in a basic neonatal set-up. Majority of the babies weighed <1500 g (43.3%). Most of the women delivered vaginally (1467/1824, 80.4%) of which 204 had breech vaginal delivery and 11 underwent instrumental deliveries. Laparotomy for rupture uterus was undertaken in 30 cases. The delivery details of cases with stillbirths are illustrated in [Table 2].
Table 2: Delivery details of cases with stillbirth

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On studying the etiology of stillbirths, placental cause accounted for 22% of cases and included abruption placenta and fetal growth restriction. Hypertension was noted in 23% women while extreme prematurity in 13%. Labor complications such as fetal distress, cord prolapse, obstructed, and prolonged labor was responsible for 9% of cases of which fetal distress was the most common cause. Maternal complications like diabetes and infection contributed to 8% of cases. Birth defects were seen in 63 (3%) cases, among which neural tube defects were the most common. However, in 22% of cases, cause of stillbirth could not be found. The causes of stillbirth are illustrated in [Table 3].
Table 3: Causes of stillbirth

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On further evaluating the etiology of stillbirth among women with and without antenatal care, it was found that labor complications, maternal infections, hypertension, and unexplained stillbirth were common causes of stillbirth in unbooked women while abruption, FGR, and birth defects were more common in booked women. The comparison of causes of stillbirths between women with and without antenatal care is shown in [Figure 1].
Figure 1: Comparison of causes between women with and without antenatal care.

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   Discussion Top


SBR is a sensitive indicator for assessing the status of maternal care in a population. At the national level, it largely reflects the quality of antepartum and intrapartum care available to pregnant women. While many developed countries have SBR as low as 3–5 per thousand births, most developing countries have rates tenfold higher; lowest being in Iceland and Denmark (1.3/1000 and 1.7/1000 births, respectively) and highest in Pakistan and Nigeria (43.3/1000 and 41.7/1000 births, respectively).[8] The SBR at our hospital during the time period from June 2017 to December 2019 was 36.15/1000 births. It is comparable to the SBR quoted by Korde-Nayak et al. in Pune (35.2/1000 births) and Kameswaran et al. in Pondicherry (35/1000 births).[9],[10] However, our SBR is higher than the Indian average of 22.6 and global average of 18.4/1000 births.[8] This is because ours is a tertiary care hospital getting referrals from east Delhi and adjoining areas of the state of Uttar Pradesh.

Almost 80% of the women were in the age group of 21–30 years which is the peak reproductive age in our country. Seven percent of the women were aged below 20 years. Similar findings were found by Kulkarni et al., with 75% of women in the age group of 21–30 years and 9% below 21 years.[11] Female literacy is another factor that influences pregnancy outcomes. In our hospital, more than 50% of women with stillbirth were illiterate while only 8% were high school pass and only 3% were graduate. In another study by Korde-Nayak et al. from Pune, 56.9% females with stillbirth were illiterate.[9] These findings are in contrast to that found by Singh and Kumar where 75.4% of the women were literate.[12] Female literacy leads to increase in awareness about antenatal care and existing health facilities and benefits of medical care during pregnancy and realization of the significance of danger signs such as decrease fetal movement, excessive edema, and headache.

Antenatal care is critical in identifying the high-risk factors and prevention of stillbirths. Twenty-nine percent of our patients had not received any antenatal care while 48% patients had been showing at some other healthcare facility like primary health care centers, private clinics and were referred to us with absent fetal heartbeat. Twenty-three percent of the patients were registered at our hospital with majority having 1–2 antenatal visits only. This is in contrast to that found by Singh and Kumar in another tertiary hospital at Delhi where 60% of women had at least four antenatal checkups.[12] The lack of quality antenatal care is a missed opportunity for the women. Focused antenatal care is a known strategy to improve maternity outcomes by early detection of complications such as anemia, hypertension, diabetes, infection, malnutrition, and appropriate intervention.

Of all the stillbirths, 58.3% were macerated fetuses, while 41.7% were fresh stillbirths. Majority of the patients had absent fetal heartbeat at the time of presentation at the hospital. 'Macerated' and 'fresh' have been used traditionally to define ante-or intrapartum stillbirth. However, these clinical features may be subjective and up to 18% of antepartum stillbirth may be fresh and up to 30% intrapartum stillbirth may be defined as macerated. Distinction between ante-and intrapartum stillbirth is critical because 50%–70% of stillbirth in LMICs are intrapartum.[13] Reduction in SBR in the developed countries is primarily due to the reduction in intrapartum SBR. Increased access to obstetric services including better intrapartum fetal monitoring and to cesarean sections appears to be associated with the decrease in stillbirth.

Around one-third of the patients with stillbirth had gestational age of 37–40 weeks (34.3%) followed by 33–36 weeks (25.4%). Similar findings were found by Singh and Kumar in their study where 54.7% of stillbirths occurred after 32 weeks of gestation.[12] In our study, a substantial portion of stillbirths, 13%, were due to extreme prematurity, i.e., period of gestation <28 weeks. Survival of babies born at such extreme of gestation is minuscule despite the best of neonatology facilities. Majority of the stillbirths (43.3%) were <1.5 kg birth weight. This is similar to the study by Singh and Kumar that observed 33.8% of stillbirth being 500–1000 g and other 46% between 1000 and 2500 g.[12] Low birth weight among stillbirths may be due to FGR, extreme prematurity, or associated congenital anomalies.

Of all the stillbirths, 54.3% were males. This is understandable considering the better survival instincts of female fetuses. Around 21% of patients had previous abortions while 6.5% patients had history of prior stillbirth. The evidence surrounding the recurrence risk of stillbirth remains controversial and limited. In a systematic review and meta-analysis of 13 cohort and 3 case–control studies, increased risk of stillbirth was found among women with a history of stillbirth in previous pregnancy (2.5%) compared with those with a history of live birth (0.4%).[14] However, the recurrence risk varies depending upon the specific etiology.

On analyzing the causes of stillbirth, placental causes including abruptio placenta and placental insufficiency (FGR) accounted for 22% of cases. Kulkarni et al. found placental insufficiency to be responsible for 26% of stillbirth in their study.[11] Three-quarters of stillbirths due to fetal growth restriction occur in the third trimester, emphasizing the need for close antenatal surveillance during this period. Hypertension was present in 23% of the cases of stillbirth. In a study from Chandigarh, hypertension accounted for about 18% of cases while in a study from Vellore, it was responsible for 27.5% of the total stillbirth.[11],[15] Proper antenatal care can significantly reduce this preventable cause of stillbirth.

Maternal medical condition accounted for 8% cases of stillbirth and included diabetes mellitus and maternal infections, of which viral hepatitis was the most common. Infection is believed to contribute to nearly half of the stillbirths in the developing countries, but in the present study it was attributable to 4% of cases only. A study from Bangladesh reported maternal infections as the cause of stillbirth in 8.9% of women while in Tanzania, it was found to be associated with 42% of stillbirths, which is ten times higher than our results.[16] Labor complications accounted for 9% cases of stillbirth among which most common causes was fetal distress followed by prolonged or obstructed labor. Some evidence-based interventions such as fetal heart rate monitoring and labor surveillance have their greatest effect on stillbirths, which is crucial for preventing 1.3 million intrapartum stillbirths and reducing neonatal deaths.[8]

Birth defects were responsible for 3% of all stillbirths in our study. Birth defects contribute to nearly a quarter of stillbirths in the developed countries but only to 5% in the developing countries.[15],[17] Most common defects were central nervous system deformities including anencephaly, neural tube defects, and hydrocephalus. Nonimmune hydrops was present in 14 cases. More emphasis should be given to folic acid supplementation to the mothers in the community who are planning to conceive so as to prevent neural tube defects.

The cause of stillbirth remained unexplained in 22% of our cases, while in studies from South India and Bangladesh 50% of cases had no identified condition.[16],[18] As per literature, the unexplained cause varies from 25% to 60% depending upon the extent of investigations. Our figure of 22% may be an overestimate as patients do not give consent for fetal autopsy due to social factors and karyotype being an expensive and not readily available investigation.

Hypertension and maternal infections were more frequently seen as cause of stillbirth in women who had not received any antenatal care as they were never screened for these and sadly ended up with stillbirth. Similarly, due to unsupervised antepartum and intrapartum periods, labor complications were more common in these women. Furthermore, etiology of stillbirth could not be found in a large proportion of these women due to lack of proper work up. Fetal growth restriction, birth defects, and abruption were more common in registered/booked patients as these are largely unpreventable.


   Conclusion Top


Stillbirth remains a neglected issue, invisible in policies and programs, underfinanced, and in urgent need of attention. In a developing country like India, it remains a largely hidden phenomenon. A significant proportion of stillbirths is preventable by adequate antenatal care. Notification of stillbirths will give us the exact figures and realization of the seriousness of the problem which will help us work towards the solutions.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
World Health Organization. International Statistical Classification of Diseases and Related Health Problems. 2nd ed., Vol. 2, 10th Rev. Geneva: World Health Organization; 2010. Available from: http://www.who.int/classifications/icd/ICD-10_2nd_ed_volume2.pdf?ua=1. [Last accessed on 2018 May 30].  Back to cited text no. 1
    
2.
Aminu M, Unkels R, Mdegela M, Utz B, Adaji S, van den Broek N. Causes of and factors associated with stillbirth in low- and middle-income countries: A systematic literature review. BJOG 2014;121 Suppl 4:141-53.  Back to cited text no. 2
    
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Blencowe H, Cousens S, Jassir FB, Say L, Chou D, Mathers C, et al, Lancet Stillbirth Epidemiology Investigator Group. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: A systematic analysis. Lancet Glob Health 2016;4:e98-e108.  Back to cited text no. 4
    
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Lawn JE, Blencowe H, Waiswa P, Amouzou A, Mathers C, Hogan D, et al. Stillbirths: Rates, risk factors, and acceleration towards 2030. Lancet 2016;387:587-603.  Back to cited text no. 5
    
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Moller AB, Patten JH, Hanson C, Morgan A, Say L, Diaz T, et al. Monitoring maternal and newborn health outcomes globally: A brief history of key events and initiatives. Trop Med Int Health 2019;24:1342-68.  Back to cited text no. 6
    
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Korde-Nayak VN, Gaikwad PR. Causes of stillbirth. J Obstet Gynecol India 2008;58:314-18.  Back to cited text no. 9
    
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Kulkarni N, Rosario DP, David LS, Vijayaselvi R, Beck MM. Decoding stillbirths using the relevant condition at death classification: Study from the developing world. J Turk Ger Gynecol Assoc 2019;20:106-16.  Back to cited text no. 11
    
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Singh A, Kumar M. An analysis of cause of stillbirth in a tertiary care hospital of Delhi: A contribution to the WHO SEARO project. J Obstet Gynaecol India 2019;69:155-60.  Back to cited text no. 12
    
13.
Patterson JK, Aziz A, Bauserman MS, McClure EM, Goldenberg RL, Bose CL. Challenges in classification and assignment of causes of stillbirths in low- and lower middle-income countries. Semin Perinatol 2019;43:308-14.  Back to cited text no. 13
    
14.
American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine. Management of Stillbirth: Obstetric Care Consensus No, 10. Obstet Gynecol 2020;135:e110-32.  Back to cited text no. 14
    
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Halim A, Aminu M, Dewez JE, Biswas A, Rahman AK, van den Broek N. Stillbirth surveillance and review in rural districts in Bangladesh. BMC Pregnancy Childbirth 2018;18:224.  Back to cited text no. 16
    
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Sharma B, Prasad G, Aggarwal N, Siwatch S, Suri V, Kakkar N. Aetiology and trends of rates of stillbirth in a tertiary care hospital in the north of India over 10 years: A retrospective study. BJOG 2019;126 Suppl 4:14-20.  Back to cited text no. 17
    
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Devi KS, Aziz N, Gala AR, Surapaneni T, Nair DH, Pant HB. Incidence of still births and risk factors at a tertiary perinatal center in southern india: retrospective observational study. Int J Gynecol Reprod Sci 2018;1:14-22.  Back to cited text no. 18
    


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