Prevalence of stillbirth deliveries and associated factors at Princess Christian Maternity Hospital, Sierra Leone, 2019 to 2022

Lilian Kumba Admire-Taylor^1,2, Adel Hussein Elduma^2,3, Amara Alhaji Sheriff², Solomon Aiah Sogbeh², Umaru Sesay², Anna Jammeh², Awol Yemane⁴, Kofi Mensah Nyarko⁵, Aminata Koroma¹, Joseph Kanu¹, James Sylvester Squire¹, Mohamed Vandi², Gebrekrstos Negash Gebru^2,&

 

¹National Public Health Agency, Sierra Leone, ²Sierra Leone Field Epidemiology Training Program, ³African Field Epidemiology Network, ⁴Aberdeen Women Centre, Sierra Leone, Freetown, ⁵University of Environment and Sustainable Development, Somanya, Ghana

 

 

^&Corresponding author
Gebrekrstos Negash Gebru, African Field Epidemiology Network, Sierra Leone (AFENET), Wilkinson Road, Freetown, Sierra Leone.

 

 

 

 

The World Health Organization (WHO) defines stillbirth as the loss of a baby at or after 28 weeks of gestation and before or during birth [1]. Two-thirds to three-quarters of stillbirths occur during antepartum, which is often caused by insults that occur in utero during the antenatal period. Some of such causes include bacterial infection, birth defects, especially pulmonary hypoplasia, maternal diabetes, hypertensive diseases in pregnancy, maternal alcohol consumption, cigarette smoking, post-term pregnancy, placenta abruption, radiation, poison, physical trauma, rhesus disease, umbilical cord accidents, and intrauterine growth restriction [2].

 

Globally, an estimated 1.9 million babies were stillborn at 28 weeks or more gestation, a rate of 13.9 stillbirths per 1,000 total births in 2021 [3]. Over the past two decades, substantial progress has been made in reducing the stillbirth rate globally, from 21.4 stillbirths per 1,000 total births in 2000 to 13.9 in 2019. However, these reductions have not kept pace with other indicators, such as under-five mortality [4]. The stillbirth gains have been much slower than the annual reduction rates for other mortality indicators, with progress lagging across all regions since 2000. The reduction in mortality for children aged 1-59 months, for example, was almost double the reduction in stillbirths (4.3 to 2.3, respectively) [4]. Approximately 98% of these stillbirths occur in low- and middle-income countries, with sub-Saharan Africa accounting for the highest stillbirth rate of 28.7/1000 total births, and most of them (61.8%) occuring in rural areas [5]. In 2014, the World Health Assembly endorsed the Every Newborn Action Plan (ENAP), which includes a global target of 12 or fewer stillbirths per 1000 births in every country by 2030.

 

In 2019, 128 high-income and upper-middle-income countries met this target, but many countries, including Sierra Leone, did not [1]. The estimated magnitude of stillbirth rates varies from low to middle-income countries. For example, Agerie et al. reported a stillbirth rate of 87 per 1000 deliveries in a hospital-based study in northwest Ethiopia[6]. A similar study conducted in a maternity unit in South Africa showed a stillbirth rate of 74.9 per 1000 births [7]. Another study in a specialized hospital in Harar, Eastern Ethiopia, showed a stillbirth rate of 145 per 1000 births[8]. In contrast, Njoku et al., at a tertiary hospital in the Niger Delta Area of Nigeria, found a stillbirth rate of 48.4 per 1,000 births[9] and a study at Buea Regional Hospital in Cameroon reported a stillbirth rate of 26 per 1000 births[10].

 

According to several studies, various factors have been linked to stillbirths; this includes antepartum hemorrhage, maternal hypertension, small weight for gestational age newborns, anaemia, asphyxia, maternal infection, non-communicable disease, chronic illness, inter-pregnancy interval, prior preterm-birth, premature rupture of membranes, induced onset of labor, and prolonged labor. Other studies also identified several factors that contribute to stillbirths, including multiple pregnancies, the mode of delivery, maternal age, residency, education level, parity, usage of prenatal care, place of delivery, body mass index (BMI), prior stillbirths, uterine rupture, and abruption of placentae [8,11,12,13,14,9,15].

 

In Sierra Leone, the stillbirth rate is 118.1 per 1000 total births, which is very high compared to other countries [16]. Sierra Leone is one of the countries with the highest maternal, newborn, and child mortality rates, as well as adolescent fertility rates globally. This was worsened by the 2014-2016 Ebola epidemic, which had a devastating impact on the healthcare system in the country. This was proven by an increase in the annualized reported stillbirths as compared to expected in 2015 and an institutional rise in the stillbirth rate of 24%[17]. As part of the post-Ebola recovery response, the government developed new national policy guidance, including the health sector recovery plan, the basic package for essential healthcare services, and the President´s Recovery Plan, demonstrating this commitment. The 2017 Sierra Leone National Reproductive Maternal, Newborn, Child and Adolescent Health (RMNCAH) Strategy 2017 to 2021 further demonstrates the country´s commitment to the health of women, newborns, children, and adolescents [18]. Even though there is limited information on stillbirth deliveries in Sierra Leone, the burden and associated factors remain unknown. This study aimed to determine the prevalence of stillbirths and identify associated risk factors among women who delivered at Princess Christian Maternity Hospital in Sierra Leone.

 

 

Study Design and Period

 

A hospital-based cross-sectional study using secondary data from delivery records was conducted to determine the prevalence of stillbirth deliveries and associated factors at Princess Christian Maternity Hospital, Sierra Leone. This study was conducted in June 2022.

 

Study Area

 

The study was conducted at the Princess Christian Maternity Hospital (PCMH), which is situated in the East I zone of Freetown in the Western Area Urban District (WAUD) (Figure 1). This hospital is the main tertiary teaching hospital of Sierra Leone and the referral facility for all government and private health facilities. It has seven units/wards: two domiciliary, one high-dependency unit, one labor ward, an ANC unit, an outpatient department, and a triage with 140 beds. The hospital has a total staff of 516, of which 425 are healthcare workers and 91 are support staff. Ten obstetricians and gynecologists, ten resident physicians, three general practitioners, two surgical health officers, nine nursing officers, 73 midwives, 13 specialized nurses, and other staff.

 

The Western Area Urban District (WAUD) is the hub of the nation´s administration, financial, educational, communication, cultural, and economic center, as well as its main port. It has a total population of 1,200,230, of which under one year is 48,009; surviving infants 43,208; under two years 96,018; under five years 212,441; pregnant women 52,810; women of childbearing 266,451 and non-pregnant women 213,641.

 

Study Participants

 

The study population comprised all delivery records for the period under study. Stillbirths can either occur in the antenatal or intrapartum period. Antenatal stillbirth is a fetal death that occurs during the antenatal period before the onset of labor, and it usually presents with signs of skin maceration, as macerated stillbirth. Intrapartum stillbirth, on the other hand, is fetal death that occurs during the intrapartum period and usually presents as fresh stillbirth without signs of skin maceration.

 

Inclusion criteria

 

All delivery records from 28 weeks of gestations (antepartum) and during delivery (intrapartum) at PCMH during the period under review from January 2019 to June 2022.

 

Exclusion criteria

 

The study excluded miscarriage deliveries that occurred before 28 weeks. It also excluded cases with incomplete variables in the delivery summary, such as missing fetal birth weight, baby's sex, mode of delivery, time of death, and baby's status.

 

Selection of study population

 

All records on live and stillbirth deliveries from January 2019 to June 2022. Data was extracted for 2019, 2020 and 2022 records, but no data was available for 2021. A total of 13,164 patient records were initially reviewed. After excluding 2101(16%) of the total records due to incomplete data or not meeting inclusion criteria, 11,063 records (84%) were included in the final analysis.

 

Data collection

 

The data collection method employed was a review of the delivery register/records using a data extraction checklist at the PCMH. The data collected were maternal demographic and clinical characteristics such as age, marital status, residence zones, gravidity, parity, mode of delivery, and type of delivery. Fetal clinical characteristics were the sex of the child, the status of stillbirth (macerated or fresh), birth weight (low <2.5kg), and birth presentation. Factors associated with stillbirth deliveries were the final diagnoses of the clinicians. Data on the total births during the study period was obtained from the records to calculate the prevalence and factors associated with stillbirth deliveries. Stillbirth was classified as “Yes” and livebirth as “No”.

 

Data management and analysis

 

The data collected were entered into Microsoft Excel 2016 for analysis and kept in a secure, password-protected computer with no personally identifiable information displayed. Data was exported to Epi Info version 7 software for further data cleaning, coding, and analysis. Descriptive statistics was performed to report measures of the central location, such as median, range, frequencies, and proportion. In this study, we considered 2019 as pre- COVID-19, 2020 to 2021 COVID-19 pandemic, and 2022 as post-COVID-19 pandemic period.

 

We considered stillbirth (yes/no= livebirth) as the outcome variable, while clinical presentation, and demographics such as antepartum hemorrhage, eclampsia, low birth weight, obstructed labor, fetal distress, age group (years) of mothers, and parity of mothers as independent variables. Simple logistic regression was conducted for each factor separately. At 95% Confidence Interval (CI), variables with p-value <0.05 were included for multiple regression analysis to adjust for co-founding effect.

 

Ethical Considerations

 

We obtained administrative approval from the Directorate of Health Security and Emergencies (DHSE) and the Medical Superintendent at PCMH to conduct this study. Ethical clearance was not required from the Sierra Leone Research and Ethics Committee, as this study involved a routine secondary data analysis. This procedural approval confirms our compliance with institutional and regulatory guidelines for research that utilizes de-identified pre-existing data sources. No identifiable information was disclosed, and participants' confidentiality was maintained through a password-protected computer accessible only to the principal investigator.

 

 

Socio-demographic and clinical characteristics

 

During the period under review, 13,164 deliveries were recorded, and 11,063 records were analyzed. Out of the total deliveries recorded, 1,097 (8.3%) were stillbirths, and the average stillbirth rate for the study period was 99.2 per 1000 total births. The median age of the mothers was 25 years (Interquartile range 21-29 years). Of the 1097 stillbirth deliveries, women in the age group 20-29 accounted for 581 (53.0%), followed by the age group 30-39 years 246 (22.4%). Married women accounted for 939 (85.6%). Multigravida accounted for 694 (63.3%), followed by primigravida 327 (29.8%) and unknown 76 (6.9%). Multiparous women accounted for 619 (56.4%), followed by nulliparous 348 (31.7%), grand multiparous 54 (4.9%), and unknown 76 (6.9%). Women who reside in East accounted for 397 (36.2%), followed by women who reside in Waterloo Rural 316 (28.7%), and women who reside in West 135 (12.3%) (Table 1).

 

Fetal clinical characteristics

 

Among the total stillbirth deliveries, 912 (83.1%) of them died during the antepartum and 185 (16.9 %) during the intrapartum period. Fresh stillbirth accounted for 599 (54.6%), followed by macerated 498 (45.4%). Birth weight ≥ 2.5 kg accounted for 657 (59.9%), followed by < 2.5 kg accounted (33.9%) and unknown 450 (6.2%). The majority, 964 (87.9%) of the stillborn babies were delivered as normal cephalic birth presentation followed by normal breech 98 (8.9%) (Table 2).

 

Our result shows a steady monthly trend of stillbirth deliveries from January to March within the study period of 47 and 63 stillbirth deliveries, respectively. However, in April 2020, the COVID-19 pandemic year, an initial decrease of 33 stillbirths was recorded. Still, in May and June of the same year, an increase of 59 and 68 stillbirth deliveries was recorded, respectively. The highest number of stillbirth deliveries, 405, was recorded in 2019, followed by 362 in 2022, with the least, 330, in 2020 (Figure 2).

 

Descriptive characteristics of stillbirth deliveries

 

Among the stillbirth deliveries, 642 (58.5%) of them had no identifiable factors, followed by women who had multiple pregnancies 89 (8.1%), while 62 (5.7%) had antepartum haemorrhage, 57 (5.2%) had placenta abruption, 47 (4.3%) had obstructed labor, 40 (3.6%) had eclampsia, 34 (3.1%) had prolonged labor, and only 14 (1.3%) had previous cesarean section (Table 3).

 

Simple and multiple regression analysis

 

From our simple regression analysis, the associated factors found to be statistically significant with stillbirth deliveries were grand multiparous (cOR=1.7, 95% CI: 1.313-2.344), antepartum haemorrhage (cOR=7.8, 95% CI: 6.192-9.90) and low birth weight (cOR=3.6, 95% CI: 3.188 - 4.206). Fetal distress (cOR=0.4 95% CI: 0.277-0.688) and obstructed labor (cOR=0.7, 95% CI: 0.705-0.564) were protective factors of stillbirth deliveries.

 

Multiple regression analysis showed that grand multiparous women had 1.6 increased odds of having stillbirth compared to the other parities (aOR=1.6, 95% CI: 1.20-2.28). Women who had APH had six-fold increased odds of having stillbirth compared to women who had no APH (aOR=6.2,95% CI: 4.55-8.42). Women who had low birth weight babies had an almost four-fold increased odds of having stillbirth compared to women who had no low birth weight babies (aOR=3.7, 95% CI: 3.18-4.29). Age group of 30-39 (aOR=0.5, 95%CI: 0.3-0.86),fetal distress (aOR=0.5, 95% CI: 0.28-0.7)) and obstructed labor (aOR=0.7, 95% CI: 0.57-0.98) were protective factors of stillbirth deliveries (Table 4).

 

Effect of COVID-19 on stillbirth rate

 

From the graph below, our result shows that the stillbirth rate in 2019 (pre- COVID-19) was 98.4 per 1000 total births, and in 2020 (COVID-19 pandemic), the stillbirth rate increased to 103.9 per 1000 total births, while in 2022, the stillbirth rate declined to 96.0 per 1000 total birth (Figure 3). However, no data exists for 2021.

 

 

This study determined the prevalence of stillbirth deliveries and identified factors associated with stillbirths at Princess Christian Maternity Hospital, Sierra Leone, from 2019 to 2022. The rate of stillbirth was found to be 99.2 per 1000 total births. This is comparable higher to similar studies conducted in the Niger Delta area of Nigeria and the Solomon Islands, in which the stillbirth rate was 48.4 and 31 per 1000 births, respectively. The rate is higher with regards to the global estimates recommended UN stillbirths rate of 12/1000 births and lower than a study conducted in Eastern Ethiopia in which the rate was 145 per 1000 births. The findings in this study could be attributed to late or poor referral services, poor antenatal care services, long distances to referral hospitals, and inadequate emergency obstetric care at referral centers [19,20,21].

 

Additionally, the majority of deliveries in the referral hospitals are complex and referred from other primary care facilities, which increases the risk of stillbirth. Out of all the stillbirth deliveries, 83.1% of them occurred during the antepartum period. Fresh stillbirths accounted for 54.6% and macerated 44.4%. The findings are similar to a multi-center study conducted in Nigeria in which the proportion of fresh stillbirths was higher,47.4%, and another study in Lagos, Nigeria, which reported similarly. This finding is contrary to a study conducted in the Niger Delta area of Nigeria, where fresh stillbirth accounted for 34.5%, and in Maiduguri, Nigeria, 47.5%. This indicates that most of the stillbirths in the present study occurred during delivery/labor (antepartum period). This is a reflection of fetal death during labor, usually an outcome of poor intrapartum care. These findings suggest the need for improved obstetric care and the availability of adequate emergency services during labor and delivery.

 

Of all the stillbirths, 58.5% had no identifiable factors. Independent factors that were associated with stillbirth deliveries included women within the age group of 30-39 years APH, low birth weight babies, obstructed labor, and fetal distress. This might be due to delays in seeking health care services. This finding is congruent with a study conducted in Ethiopia on the magnitude and determinants of stillbirth in Mizan-Tepi Teaching Hospital, Southwest Ethiopia [22]. This similarity might be because both studies were conducted in a referral teaching hospital.

 

Our findings revealed that women within the age group 20-29 years had more stillbirth deliveries than other age groups. Our findings revealed that women within the age group of 30-39 had less stillbirth deliveries than the other age groups. The finding that the mothers aged 30-39 years had significantly lower odds of stillbirth compared to older mother aged 40-49 can be explained by several reasons. Firstly, women aged 30-39 are at their peak reproductive potential, i.e. they will have less fertility issues and comorbidities that can compound stillbirth. This population have fewer chromosomal abnormalities compared to the older category. Secondly, older mothers have multiple comorbidities which likely leads to pregnancy termination and subsequent stillbirth. Finally, older mothers face more challenges in accessing quality healthcare thus affecting the pregnancy outcome. [23,12]. These factors collectively contribute to a higher chance of stillbirth. However, we were not able to explain the low odds of stillbirth of those 30-39 compared to younger mothers. To clarify this finding, a further prospective study is recommended.

 

Our study also revealed that stillbirth was more seen in multiparous women than in the other parities. This finding is congruent with a study conducted in East African countries on the prevalence of stillbirth and its associated factors in East Africa by Tesema et al.[24], where multiparous women accounted for the highest stillbirth delivery mothers, and similarity may be due to the grouping of the parities. Furthermore, our study showed that stillbirth was common among women who experienced spontaneous vaginal delivery. This finding is consistent with a study conducted at Hiwot Fana Specialized University Hospital in Harar, Eastern Ethiopia, where stillbirth was more common among women who experienced spontaneous vaginal delivery, and similarities may be due to single facility-based studies[8].

 

Nonetheless, our findings showed that women from the East zone had more stillbirth deliveries than those from the other zones. This might be due to inadequate government maternal health facilities allocation in that zone and findings similar to that done on predictors of stillbirth among women who had given birth in Southern Ethiopia, where women from rural areas had more stillbirth deliveries than urban areas. The variation in these studies might be due to delays in seeking health care services. Moreover, our findings showed more fresh stillborn babies than macerated. This might be due to poor maternal history and delay in seeking health care services [25,26,27].

 

A study conducted in Mpilo Central Hospital, Bulawayo, Zimbabwe, reported different findings where a large proportion of stillbirths were macerated [28]. The finding of this study observed a spike in the stillbirth rate during the COVID-19 pandemic waves and a gradual decline when the COVID-19 cases declined. This might be due to a lack of antenatal care and skilled delivery services for fear of contracting COVID-19 infection when pregnant women visit health facilities and lockdowns in the country. A study conducted in Nigeria on stillbirths also found that newborn deaths increased during the COVID-19 pandemic [29].

 

Furthermore, our multiple regression analysis showed that women who had APH had higher odds of having stillbirth deliveries compared to those who did not. This might be due to APH being the leading cause of placenta abnormalities [30].

 

This study´s findings also showed that mothers who delivered babies with low birth weights were more likely to have stillbirths. This might be due to low-birth-weight babies having a high tendency of preterm delivery. A similar finding was reported by a study conducted in Ghana, where the prevalence of low birth weight was considered a risk factor for stillbirth [31].

 

Our findings showed that women who delivered babies with fetal distress were less likely to deliver stillbirth. The existing scientific knowledge indicates that fetal distress is considered a risk factor for stillbirth. However, the finding of this study contrasts with that, possibly because most pregnancies showing signs of fetal distress might have received interventions such as cesarean section or instrumental delivery, leading to live birth [32]. This study also showed that obstructed labor was found to be protective against stillbirth. Contrary to our findings, a wide range of literature suggests obstructed labor to be a predisposing factor for stillbirth. As obstructed labor is considered to be neglected prolonged labor, the fetal outcomes are usually dismal; obstructed labor is usually related to uterine rupture, hemorrhage, and sepsis, which all increase the chance of stillbirth. The observed discrepancy may be due to the lack of a clear definition for the diagnosis of obstructed labor. Clinically, the distinction between cephalopelvic disproportion and obstructed labor is often unclear, as cephalopelvic disproportion is typically an earlier form of obstructed labor. If cephalopelvic disproportion is not managed timely, it leads to obstructed labor. The cesarean sections for cephalopelvic disproportion are maternal indications, so the fetal outcomes are usually good [33,34,35]. Thus, most cases might have been misclassified as obstructed labor while actually being Cephalopelvic disproportion. To clarify this contradictory finding, further prospective studies with a clear operational definition of CPD and obstructed labor are required.

 

Limitations

 

We were unable to analyze 2021 data due to missing variables. This study was conducted in one health facility, which can affect its generalizability and the actual burden of stillbirth in the country. Additionally, the clinical registers did not state the number of congenital abnormalities. This study could not establish the link between the COVID-19 status of the women and stillbirths because the COVID-19 status of the women who delivered during the pandemic was not captured in the registry.

 

 

The prevalence and rate of stillbirths found in this study were high, while antepartum hemorrhage, grand multiparous, and low birth weight were associated with stillbirth deliveries. COVID-19 impacted stillbirth deliveries in 2020, as there was a drop in the total deliveries in that year. The findings provided insights into the country's progress toward achieving the Sustainable Development Goal (SDG) target 3.2. Additionally, this research contributes to the existing knowledge on stillbirths in Africa and provides evidence to enhance public health and clinical interventions. We have communicated our findings to the DHSE and PCMH management, emphasizing the importance of accurately completing all variable columns in delivery registers and handling them carefully. Additionally, we have educated staff regarding the significance and utilization of clinical data. Given that an identifiable cause was not determined in most stillbirth cases (58.6%), we suggest conducting prospective studies. Furthermore, we recommend carefully monitoring pregnant women with maternal complications during antenatal clinic visits, improving transportation services for delivering mothers and enhancing the quality of intrapartum care.

 

 

The authors declare no competing interests.

 

 

Conceptualization and design: LKAT, AHE, GNG. Data Collection: LKAT. Analysis and Interpretation: LKAT, AHE, GNG, AW. Drafting and Review of Manuscripts: LKAT, AHE, AAS, SIS, US, AJ, AY, KMN, ATK, AY JSK, JSS, MAV, GNG. All authors approved the manuscript.

 

 

We thank the management of Princess Christian Maternity Hospital (PCMH), the Ministry of Health, the Sierra Leone Field Epidemiology Training Program, mentors and colleagues, the United States Centers for Diseases Control and Prevention, the African Field Epidemiology Network, and all those who contributed to this study's success.

 

 

Table 1: Maternal socio-demographic characteristics of stillbirth deliveries, at PCMH, January to June 2019, 2020 and 2022

Table 2: Fetal clinical characteristics of stillbirth deliveries, at PCMH, January to June 2019, 2020 and 2022

Table 3: Descriptive of stillbirth deliveries at PCMH, January to June 2019, 2020 and 2022

Table 4: Bivariate and multivariate logistic analysis of factors associated with stillbirth deliveries at PCMH, January-June 2019, 2020, and 2022

Figure 1: Map of Sierra Leone showing Princess Christian Maternity Hospital, January to June 2019, 2020 and 2022

Figure 2: Monthly trend of stillbirth deliveries at PCMH, January to June 2019, 2020, and 2022

Figure 3: Stillbirth rate per 1000 total births at PCMH, January to June 2019, 2020, and 2022

 

 

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