Risk factors associated with stillbirth in Kigeme district hospital, Rwanda: A case-control study

Hagabimana Aphrodis^1,3,&, Nzabonimana Ephraim¹, Kagimbangabo Jean Marie Vianney¹, Musafili Aimable², Ndagijimana Albert²

 

¹Kigeme District Hospital, Nyamagabe, Rwanda, ²Department of Pediatrics and Child Health, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda, ³University of Rwanda, College of Medicine and Health sciences, School of Public health, Kigali, Rwanda

 

 

^&Corresponding author
Hagabimana Aphrodis, Kigeme District Hospital, Nyamagabe, Rwanda, University of Rwanda, College of Medicine and Health sciences, School of Public health, Kigali, Rwanda.

 

 

 

 

Stillbirth is defined as the birth of an infant that has died in the mother´s womb, strictly, after having survived through at least, the first 28 weeks of pregnancy and at 1000gr birth weight; the death of the fetus could have occurred before the onset of labor or at the time of delivery [1,2].

 

Stillbirth remains a public health problem as well as a developmental problem in low and middle-income countries [3,4]. In 2015, there were an estimated 2.6 million of stillbirths worldwide, with 98% occurring in low and middle-income countries; 75% of them were reported in sub-Saharan Africa and Asia with a rate of approximately 25.5 and 29.7 per 1000 births respectively [4,5].

 

Globally there were 18.4 stillbirths per 1000 total births and the global average annual rate of reduction for stillbirths was 2.0% according to WHO report 2015 [6]. This shows a long journey to make towards the corresponding Sustainable Development Goal (SDG) with the target of 12 or fewer stillbirths per 1000 births in every country by 2030 [7].

 

In developing countries, the risk factors for stillbirth include advanced maternal age, maternal educational level, infections during pregnancy, lower birth weight, and labor complications has been linked to stillbirth [8,9]. Improved health care at birth and services of antenatal care visits (ANC) are essential to prevent 1.3 million stillbirths [4].

 

Each country should focus on using data to document preventable risk factors of stillbirth and act accordingly [10]. Rwanda health statistics in 2016, reported a stillbirth rate of 18 per 1000 births [11]. According to Kigeme district hospital health database, the proportion of stillbirths was decreased slowly; from 3.0% in 2017, 2.4 in 2018 to 2.26% in 2019. However, little is known on the associated risk factors related to stillbirth. Therefore, this study aimed to determine the risk factors associated with stillbirth by using a more comprehensive database to guide future preventative care efforts and depict out the major risks factors of stillbirths in Kigeme District Hospital, for evidence-based actions to reduce and prevent stillbirths.

 

 

Study design

 

This study used a 1:4 unmatched case-control design to determine the risk factors associated with stillbirth. Cases were defined as any stillbirth that had occurred in the maternity unity of Kigeme district hospital. Controls were defined as two live births that occurred closely before the stillbirth and two after stillbirth in maternity unity.

 

Study setting

 

The study was conducted in the Maternity unit of Kigeme district hospital, Nyamagabe, Rwanda. Kigeme district hospital is one of two district hospitals located in Nyamagabe district, Southern Province of Rwanda. It has ten health centers in the catchment area with approximately 209,543 populations. The hospital performed 4,472 deliveries between January 2018 and December 2019 of which 121 ended-up stillbirths.

 

Study population and sampling

 

The study targeted mothers who gave birth to a stillbirth at Kigeme District Hospital from January 2018 to January 2019. Mothers who did not give birth in the hospital and those stillborn babies with weight of less than 1000g were excluded. Using the proportion formula of a ratio of 1:4, a minimum sample size of 605 (121 cases and 484 controls) was calculated. Cases and their corresponding controls that met the inclusion criteria were all selected.

 

Data collection

 

Data were collected from patients´ files and registers by the trained midwives working in maternity unit, using a data extraction form designed in Epi Info 7 (version March 2015, CDC Atlanta). Records were extracted on socio demographic information, gynecological and obstetrical patterns, newborn information, environmental, modifying patterns and medical information during pregnancy.

 

Data analysis

 

All the study participants´ characteristics of categorical variables were summarized using frequencies and percentages. Mean and standard deviation were used to describe continuous variables. A bivariate analysis was performed through a binary logistic regression, with crude odds ratio (COR), 95% CI and p-value. All significant variables from the bivariate analysis were gathered through the multivariate analysis used a logistic regression model to estimate the adjusted odds ratio (aOR). Age was also included in the reduced model to control for its potentially confounding effect. Statistical significance was set at 95% CI and p value < 0.05. The analysis was performed using STATA 16 (StataCorp).

 

Ethical considerations

 

Ethical approval with Ref. No 63/07.02.05/20/HOPKG/2020 was obtained from Kigeme district hospital ethical committee where the study was conducted. As the study used secondary data, the consent form for participants was not necessary. However, the confidentiality was ensured at all levels of data handling and management. Personal information that could lead to the identification of the participant was not collected, data were protected into password coded computers and completed form were kept well and accessed by the only authorized staff.

 

 

The study extracted records from 605 mothers. The mean age was 29 years old with standard deviation of 6.3, and the majority of mothers (71.24%) were aged between 21-34 years old, 85.29% were married, 79.17% completed primary level education, 84.56% were farmers, 72.23% attended four antenatal care (ANC) visits, 97.19% just delivered a single baby, 96.20% had no previous history of stillbirth, 63.31% had gravidity of more than two times, 39.83% delivered through normal spontaneous vaginal, 84.79% delivered at ≥ 37 gestation age (weeks), 59.83% did not present any complication in labor, 60.66% had one child, 98.84% were HIV- negative, 96.43% did not present hemorrhage history during pregnancy, 98.35% tested negative for syphilis, 99.17% were malaria negative, 96.36% did not have hypertension, 97.52% were not anemia, 98.84% did not have urinary tract infection, 76.20% delivered during weekdays, 91.32% gave birth to babies of ≥ 2,500 gr, and 78.26% have given birth to female babies (Table 1).

 

The study assessed the statistical relationship of the study participants´ variables between cases and controls. It found that mothers who were 35 years old were 3.04 times more likely to have a stillbirth compared to those under 21 years old (COR:3.04; 95% CI:1.004-9.199). Mothers who attended less than four ANC visits were 3.13 times more likely to have stillbirth than those who attended four ANC visits or above (COR:3.13; 95% CI:2.066-4.741). Mothers who delivered multiple (twins) babies were 2.91 times more likely to have a stillbirth than those who delivered a single baby (COR: 2.91; 95% CI: 1.084-7.811). Mothers who were vaginally assisted during delivery were almost twice more likely to have a stillbirth compared to whom went through a normal spontaneous vaginal delivery (COR: 1.92; 95% CI: 1.219-3.052). There was 89% lower likelihood of having a stillbirth among mothers who delivered at ≥ 37 gestation age (weeks) compared to those delivered at <37 gestation age (COR: 0.11; 95% CI: 0.691-0.182). Mothers who faced labor complications were 2.08 times more likely to have a stillbirth than those who delivered with no labor complications (COR: 2.08; 95% CI: 1.391-0.3.113). Mothers with hemorrhage history during pregnancy were 6.20 times more likely to have stillbirth than those without it (COR: 6.20; 95% CI: 2.682-14.339). Mothers with malaria history during pregnancy were 6.12 times more likely to have a stillbirth compared to their counterparts without it (COR: 6.12; 95% CI: 1.0123-37.08). Mothers who delivered during weekend time were 1.63 times more likely to have a stillbirth compared to women who delivered during weekdays (COR: 1.63; 95% CI: 1.051-2.535). Babies with low birth weight (< 2,500grams) were 9.37 times more likely to be stillbirth compared to babies born with weight ≥ 2,500 grams (COR: 9.3; 95% CI: 5.816-15.10) (Table 1).

 

Factors associated with stillbirths in Kigeme district hospital

 

All significant variables from the bivariate model were put into a full multivariate logistic regression to determine factors statistically associated with stillbirth among women who have given birth at Kigeme district hospital, maternity unit. Mothers who attended less than four ANC visits were almost twice more likely to have stillbirth than those who attended four ANC visits or above (AOR: 1.94; 95% CI: 1.163-3.262). Mothers who were vaginally assisted during delivery were 1.83 times more likely to have a stillbirth (AOR: 1.83; 95% CI: 1.059-3.184) and those who delivered through cesarean section had 82% lower likelihood to give birth to a stillbirth compared to whom went through a normal spontaneous vaginal delivery (AOR:0.18; 95% CI: 0.086-0.386). Mothers who had complication in labor were 5.31 times more likely to have a stillbirth than those delivered without it (COR: 5.31; 95% CI: 2.892-9.751). Those presented hemorrhage were 7.47 times more likely to have a stillbirth than those who did not (COR: 7.47; 95% CI: 2.700-20.669). The babies born with weight < 2,500grms were 5.63 times more likely to be stillbirth compared to babies born with weight ≥2,500 grams (COR: 5.63; 95% CI: 3.216-9.857) (Table 2).

 

 

The study aimed to determine the risk factors associated with stillbirth in Kigeme district hospital from 2018 to 2019. This study found the mothers who attended less antenatal care visits were twice more likely to have a stillbirth compared to those who attended at least four times antenatal care visits. This was consistent with a study conducted in Northern Tanzania to determine maternal and fetal risk factors for stillbirth whereby it was found that mothers who visited the ANC services less than 4 times were 2.12 times more likely to give have a stillbirth that those who completed 4 or more visits [12]. Another study conducted in Rwanda found a higher perinatal mortality (macerated or fresh stillbirth) among mothers attend at least one antenatal care visit compared to mothers attend the recommended four antenatal care visits [13]. A study conducted in India has identified lack of antenatal care as a modifiable risk factor for stillbirth [14]. Attending ANC visits as recommended has a good impact in reduction of the risk of stillbirths [15]. Encouraging mothers to seek antenatal care help in the early detection of conditions that may lead to pregnancy complications and so decrease stillbirths [16], given that about one-third of all stillbirths can be predicted in the first trimester of pregnancy [17].

 

The results of this study found that the mode of delivery was associated to stillbirth. Mothers who delivered through assisted vaginal delivery were almost twice more likely to have stillbirth and those who delivered through caesarean section were 89% less likely to have stillbirth compared to women delivered through spontaneous vaginal. A study done in London, United Kingdom, has demonstrated an increased risk of stillbirth among caesareans and assisted deliveries [17]. Contrary, a study conducted in Pakistan on systematic review found that the caesarean section were the protectors against stillbirth [18]. The most caesarean sections done in this study were performed on mothers who had a live birth than stillbirth; however, most proportion of stillbirths were linked to the mothers had labor complications (Table 1). The performance of caesarean section could be the consequence of complications leading to stillbirth rather than the caesarean section being a risk factor for stillbirth [15]. Mothers who faced labor complications were 5.31 more likely to have a stillbirth than those without labor complications. This collaborates with findings from a study conducted in Zimbabwe that reported a risk of 7.56 [15].

 

Mothers with a history of hemorrhage during pregnancy were 7.49 times more likely to have a stillbirth compared to mothers without it. A study conducted at referral tertiary health facility in Benin, Nigeria found that obstetric hemorrhage account for the highest rate of stillbirth compared with other primary obstetric factors [18].

 

Low birth weight newborns had 5.63 times more risk to be stillbirth compared to those who were born with 2500grams or above. This is similar to a study conducted Ethiopia and Zimbabwe with adjusted odd ratio of 5.6 and 9.5 respectively [15,19].

 

 

Our study aimed to determine the risks factors associated with stillbirth in Kigeme district hospital. Less number of antenatal care visit, vaginal assisted delivery, obstetric hemorrhage, low birth weight and labor complications were associated with stillbirth in Kigeme district hospital, maternity unit. Caesarean section was the only protective factor for stillbirth. These findings should serve as reference for health care providers and partners in maternal and child health sector towards strengthening interventions to reduce the stillbirths. Antenatal care visit and surveillance should be proper monitored in health facilities and proper action can be taken to decrease low birth weight. Caesarean section should be encouraged to mothers with experienced labor complications. An emphasis on the quality of care and adequate management of labor complications during delivery should be considered to decreasing stillbirths in Kigeme District Hospital and other health facilities of the same level of service delivery.

 

 

The authors declare no competing interests.

 

 

Conceptualization: HA, NA. Data curation: HA, KJMV, NA. Formal analysis: HA, K JMV, MA, NA. Investigation: HA, NE, KJMV, NA. Methodology: HA, KJMV, NA. Project administration: HA, KJMV. Software: HA, NA. Supervision: NE, KJMV, NA. Validation: HA, NE, KJMV, MA, NA. Visualization: HA, NE, KJMV, MA, NA. Writing original draft: AH. All authors read and approved the final version of the manuscript.

 

 

Authors are thankful of the management of University of Rwanda and KDH for having granted the permission to conduct this study.

 

 

Table 1: Description of characteristics of the participants and statistical association with stillbirth in Kigeme DH from 2018-2019

Table 2: Multivariate analysis of risk factors associated with stillbirth in Kigeme District Hospital from 2018-2019

 

 

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