|Year : 2017 | Volume
| Issue : 1 | Page : 19-24
A 4-year retrospective review of stillbirths at the Federal Teaching Hospital, Abakaliki, Southeast Nigeria
Anthony T Agbata MBBS, MPH, FWACS 1, Justus N Eze1, Chukwuemeka I Ukaegbe1, Bartholomew N Odio2
1 Department of Obstetrics and Gynecology, Federal Teaching Hospital, Abakaliki, Ebonyi State; Department of Obstetrics and Gynecology, Ebonyi State University, Abakaliki, Ebonyi State, Nigeria
2 Department of Obstetrics and Gynecology, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
|Date of Web Publication||5-Jul-2017|
Anthony T Agbata
Department of Obstetrics and Gynecology, Federal Teaching Hospital, P.M.B. 102, Abakaliki, Ebonyi State
Source of Support: None, Conflict of Interest: None
Objective: Stillbirth is one of the most common adverse outcomes of pregnancy, yet among the least studied. The objective of this study was to estimate stillbirth rate and describe maternal and obstetric characteristics of stillbirths at the Federal Teaching Hospital, Abakaliki (FETHA), Ebonyi State, southeast Nigeria. Material and Methods: This was a 4-year review of stillbirths at the FETHA, from January 2012 to December 2015. All stillbirth folders were retrieved and relevant information entered in a proforma designed for the study. Statistical analysis was performed using IBM SPSS Statistics for Windows, version 24.0 (IBM Corp., Armonk, NY). Stillbirth rate was calculated as a proportion of total births. Results were presented as mean ± standard deviation, rates, and percentages/proportions. Results: A stillbirth rate of 41.4 was calculated for this study. The mean age for stillbirth was 28.8 years ± 5.4 (range 17–45 years). The median parity was 3, with a range of 0 to 13. About 68.8% or 276/401 of the women were unbooked. Among women who had stillbirths, only about 14% had tertiary education. Women of low social class constituted the greatest percentage (73.5%) who experienced stillbirth. The proportion of male stillbirths was higher than female stillbirth (54.1% or 216/392). About 58.4% or (230/394) of the stillbirths turned out to be macerated. In about 22.4% of cases, the immediate complication leading to stillbirth was not indicated. None of the stillbirths had autopsy performed. Conclusion: The stillbirth rate of 41.4 per 1000 observed at the study center was high. This reflects the overall picture in developing countries. A major finding from the study is the absence of postmortem examination to determine cause of stillbirth. This may be a major challenge in the effort to reduce stillbirth rate in resource-poor setting like ours.
Keywords: Abakaliki, maternal and obstetric characteristics, review, stillbirth
|How to cite this article:|
Agbata AT, Eze JN, Ukaegbe CI, Odio BN. A 4-year retrospective review of stillbirths at the Federal Teaching Hospital, Abakaliki, Southeast Nigeria. Afr J Med Health Sci 2017;16:19-24
|How to cite this URL:|
Agbata AT, Eze JN, Ukaegbe CI, Odio BN. A 4-year retrospective review of stillbirths at the Federal Teaching Hospital, Abakaliki, Southeast Nigeria. Afr J Med Health Sci [serial online] 2017 [cited 2018 Oct 19];16:19-24. Available from: http://www.ajmhs.org/text.asp?2017/16/1/19/209492
| Introduction|| |
Stillbirth, defined by the World Health Organization as a baby born with no signs of life at or after 28 weeks gestation, is one of the most common adverse outcomes of pregnancy, yet among the least studied. Every year about 2.6 million stillbirths occur, especially in low-resource countries.,, Nigeria, with a stillbirth rate of 41.7 per 1000 births, accounts for one of the highest rates in the African continent. Stillbirth rates remain nearly 10 times higher in low–middle-income countries than high-income countries., Stillbirth rates are particularly high in low-income countries because of many factors associated with poverty, such as poor access to basic obstetric care, lack of skilled birth attendants, and high burden of infectious morbidities. Available figures quoted for stillbirth rates across Nigeria reveal the magnitude of this problem.,,,,,, Unfortunately, stillbirths are not seen in this light. This attitude, coupled with ignorance, poverty, and negative sociocultural and faith beliefs are a major impediment to stillbirth prevention.,,,
Stillbirth rates are very important indicators of the quality of obstetric care available in any setting. In Nigeria, “stillbirths” are still missing in our national systems for vital registration. Lack of a well-defined program agenda, coupled with the lack of data, and social invisibility, deter action and investments for stillbirth prevention and reduction. It is against this backdrop that we undertook this study to estimate stillbirth rate and describe maternal and obstetric characteristics of stillbirths at the Federal Teaching Hospital, Abakaliki (FETHA), southeast Nigeria. The findings derived from this study are crucial in understanding the distribution and pattern of sociodemographic factors of stillbirth in a resource-poor setting like ours.
| Materials and Methods|| |
This was a cross-sectional study of stillbirths at the FETHA, Ebonyi State, over a 4-year period, from January 2012 to December 2015. FETHA, originally established as a Federal Medical Center in 1991, received an upgrade to its status of a Federal Teaching Hospital on December 7, 2011, when it was merged with the former Ebonyi State University Teaching Hospital, Abakaliki. The Teaching Hospital is situated in the center of Abakaliki, the state capital. FETHA is the only tertiary health care facility in Ebonyi State, and it handles referrals from the entire state. It has an average annual delivery rate of just over 2000. The obstetrics unit of FETHA is equipped with standard health care facilities and has the capacity and manpower to effectively manage obstetric emergencies. Ebonyi is mainly rural with about 75% of the population living in the rural areas. The main occupation of the people of Ebonyi state is farming. Poverty is widespread and reflects on the health indices of the state. As in most parts of the country, health service delivery in Ebonyi State is structured into a three-tier system with the primary health care at the base, supported by the secondary and tertiary health care levels. However, the health system in the state is extremely weak with the primary and secondary health care levels virtually collapsed. In many of the rural areas, traditional medical practitioners provide much of the health services such that traditional birth attendants are the mainstay for maternal and child health services.
All cases of stillbirth at the study center during this 4-year review period were identified through the admission and labor ward register. The folders of the affected mothers were retrieved from the medical records department, and all relevant information recorded in a proforma designed for the study. Stillbirth was defined as any baby born with no signs of life at or after 28 weeks. In our facility, death-to-delivery interval is generally based on fetal appearance as assessed by the physician, nurse, or midwife at delivery. The cross-sectional design of the study made it impossible to accurately estimate time of fetal death with a view of classifying stillbirth into fresh or macerated cases. However, several authors,, have included an approximate time frame for the development of several stages of maceration. Signs of skin maceration begin at 6 to 12 h after fetal death and therefore fetuses that showed skin and soft tissue changes (skin discoloration, redness, peeling, and breakdown) were recorded as macerated, whereas a fresh appearance of the skin with no signs of maceration is judged as a surrogate measure for fresh stillbirth. Variables analyzed for the study include age, parity, booking status, gestational age at delivery, type of stillbirth, mode of delivery, and pregnancy complications. Women were categorized into three groups based on parity: low parity (para 0 and 1), moderate parity (para 2 to 4), high parity (para 5 and above). The women were grouped into social classes using the classification of Olusanya et al. The “unbooked” category was defined as women who were not registered for antenatal care in the study center. Case-wise analysis of data was performed by excluding all folders with missing values for each variable of interest. Ethical approval for the study was issued by the Ethics and Research Committee of the Hospital.
| Statistical Analysis|| |
Statistical analysis was performed using IBM SPSS Statistics for Windows, version 24.0 (IBM Corp., Armonk, NY). Stillbirth rate was calculated as a proportion of total births. Frequency analysis was used to determine the frequencies and percentages of demographic and obstetric characteristics of the women who had stillbirth. Summary statistic for categorical variables were presented as rates, proportions and percentages, while those for numerical variables were presented as mean with standard deviation.
| Results|| |
A total of 438 entries of stillbirths were made in the admission/labor ward register. Out of the total entries, 401 folders were retrieved from the medical records department and analyzed. During the 4-year review period (2012 to 2015 inclusive), there were 9670 births and 401 stillbirths, giving a hospital stillbirth rate of 41.4 per 1000 births. The ages of the women who had stillbirth ranged from 17 to 45 years with a mean of 28.8 years ± 5.4. The median parity was 3, with a range of 0 to 13. [Table 1] shows the maternal characteristics of stillbirth. Majority (68.8% or 276/401) of the women were unbooked patients who presented to the hospital with pregnancy complication(s). Among women who had stillbirths, 56.7% (219/368) had primary education, 29.3% (113/386) had secondary education, whereas 14% (54/386) had tertiary education. Women of “low social class” constituted the greatest percentage (73.5%) who experienced stillbirth. The fetal characteristics of stillbirth are shown in [Table 2]. The proportion of male stillbirths was 54.1% (216/392) against 44.9% (176/392) for the females. A greater proportion (58.4% or 230/394) of the stillbirths turned out to be macerated. The most common reported pregnancy complication seen in this series was fetal distress (28.2%), followed by abruption placenta (17%). In about 22.4% of cases, the immediate complication leading to stillbirth was either not indicated on the folder or unknown. The most common mode of delivering stillbirth in this health facility was through the vaginal route (211/385 or 55.8%), followed by the abdominal route (103/385 or 26.8%). Preterm stillbirths were more common than term stillbirths, with majority of stillbirths (41.7%) occurring from 28 to 33 weeks of gestational age. None of the stillbirths had postmortem done.
|Table 1: Maternal characteristics of stillbirth with column proportions shown as summary statistics|
Click here to view
|Table 2: Fetal characteristics of stillbirths with column proportions shown as summary statistics|
Click here to view
| Discussion|| |
This 4-year review of stillbirth at the FETHA yielded a stillbirth rate of 41.4 per 1000 total births. This figure was compared with other rates reported across the country.,,,,,, A rate of 46.9 per 1000 was reported by Suleiman et al. in Katsina, North Western Nigeria, in 2015, whereas a rate of 180 per 1000 was reported at the Imo State University Teaching Hospital, Orlu, in 2012. These figures reflect the high stillbirth rates seen in developing countries, of which Nigeria is a major contributor. The disparity in stillbirths between developing and developed nations is quite remarkable. Finland has the lowest reported rate at 2.0 per 1000 total births, and Nigeria (41.7 per 1000 total births) and Pakistan (46.1 per 1000 total births) have the highest estimated rates. This review showed that a significant proportion of “unbooked” mothers experienced stillbirth. This high proportion of “unbooked” cases may be because of the referral status of the hospital, with a major proportion of women, some of whom may have received antenatal care elsewhere being classified as “unbooked” cases when they arrive as emergencies. The “unbooked” status in this sense may therefore not necessary mean absence of antenatal care. Women categorized as “low social class” contributed the greatest proportion of stillbirth. In most studies, social class is a crude measure of relative differences in socioeconomic conditions, which may reflect differences in health-seeking behavior of women and the subsequent influence on reproductive health outcomes. This observation is very important as it provides a clear challenge to governments that initiatives to reduce stillbirths cannot be confined only to health care interventions, but will also require social safety nets to improve health outcomes. Majority of the women (60.6%) who had stillbirths in this series were in the age range “25 to 34” years. A similar observation was reported by Okeudo et al. at a tertiary hospital in Orlu, southeast Nigeria. Other researchers have reported comparable figures from Pakistan, India, and Nepal.,, In contrast, stillbirths have been reported among old aged (>35 years) mothers from developed countries.,
The male-to-female ratio for stillbirth in this study was 1.2:1. Evidence has shown that male babies are at a 10% higher risk of stillbirth than female babies. There is evidence from few low-income countries that up to 70% of stillbirths occur as fresh stillbirths, and are due to obstetric emergencies., Macerated stillbirth constituted about 57.1% of the stillbirth in this study. This contrasts with previously published work from centers in Nigeria and some other developing countries in which fresh stillbirth constitute the majority., Nevertheless, this trend underscores the need for prompt availability and accessibility of emergency obstetric care during the labor and delivery process. The high proportion of macerated stillbirth observed in this study may have resulted from multiple factors such as late arrival of mothers, which may result from delayed referral by health personnel, long distance, lack of transport, and lack of awareness resulting in long hours of intrauterine retention of the dead fetus. These situations are quite common in resource-poor settings like ours. When fetal death during labor occurs at home, and delay in access to care is more than 6 to 12 h, the assessment of the fetal skin appearance becomes unreliable as a surrogate measure for time of death and tends to underestimate intrapartum stillbirth events. These situations are usually seen in cases of neglected prolonged obstructed labor, with fetal demise occurring long before presentation in hospital. Umeora and Egwuatu had commented on the contribution of unorthodox medical facilities to the delays subsisting maternal mortality in a rural, poor, and illiterate community in Abakaliki.
Fetal autopsy examination remains our best tool for understanding and classifying the causes of stillbirth. However, in resource-poor settings like ours, even with a hospital delivery, autopsies on the dead fetuses as well as placenta histological studies are rarely carried out. It is therefore not surprising that there was no single fetal autopsy performed at the study center during the review period. This observation may not be peculiar to our setting as a similar finding has been reported by another investigator in southeast Nigeria. In Australia, barriers to gaining consent for fetal autopsy in nonindigenous Australian women have been identified as a big challenge. These barriers that arise from negative sociocultural and faith beliefs,,,, coupled with negative psychological responses associated with stillbirth, may be a major challenge in our setting.
There are some limitations to this study. The referral nature of the hospital may have contributed to a disproportionately high numerator figure for the stillbirth rate. Another limitation, arising from the retrospective study design, was the presence of missing data from case notes. As such, data was analyzed case-wise, producing different denominators for the descriptive statistics. This strategy may produce a biased estimate of the population of interest. Classification of stillbirth into “fresh” or “macerated” cases was by external fetal examination findings made by the health care provider at the time of birth. This method has however been validated for estimating the time of death in many stillborn.
| Conclusion|| |
The stillbirth rate of 41.4 per 1000 observed in the study center was high. This reflects the overall picture seen in developing countries. A major finding from the study is the absence of postmortem examination to determine cause of stillbirth. This may be a major challenge in the effort to reduce stillbirth rate in resource-poor setting like ours.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Maternal, Newborn, Child and Adolescent Health. Stillbirths. 2013.
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.
Cousens S, Blencowe H, Stanton C, Chou D, Ahmed S, Steinhardt L et al.
National, regional, and worldwide estimates of stillbirth rates in2009 with trends since 1995: a systematic analysis. Lancet 2011;377:1319-30.
McClure EM, Pasha O, Goudar SS, Chomba E, Garces A, Tshefu A et al.
Global Network Investigators. Epidemiology of stillbirth in low-middle income countries: a Global Network Study. Acta Obstet Gynecol Scand 2011;90:1379-85.
LI Y, Yang J, Li S, Yao L. National, regional and worldwide estimates of stillbirth rates. Lancet 2011;378: 873.
Stringer EM, Vwalika B, Killam WP, Giganti MJ, Mbewe R, Chi BH et al.
Determinants of stillbirth in Zambia. Obstet Gynecol 2011;117:1151-9.
Audu B, Alhaji M, Takai U, Bukar M. Risk factors for stillbirths at University of Maiduguri Teaching Hospital, Maiduguri, Nigeria: a cross-sectional retrospective analysis. Niger Med J 2009;50:42-6. [Full text]
Ekure EN, Iroha EO, Egri-Okwaji MTC, Ogedengbe OK. Perinatal mortality at the close of the 20th century in Lagos University Teaching Hospital. Niger J Paediatr 2004;31:14-8.
Ezugwu EC, Onah HE, Ezegwui HU, Nnaji C. Stillbirth rate at an emerging tertiary health institution in Enugu, southeast Nigeria. Int J Gynaecol Obstet. 2011;115:164-6.
Mutihir JT, Eka PO. Stillbirths at the Jos University Teaching Hospital: incidence, risk, and etiological factors. Niger J Clin Pract 2011;14:14-8.
] [Full text]
Okeudo C, Ezem B, Ojiyi E. Stillbirth rate in a teaching hospital in South-eastern Nigeria: a silent tragedy. Ann Med Health Sci Res 2012;2:176-9.
] [Full text]
Onadeko M, Lawoyin T. The pattern of stillbirth in a secondary and a tertiary hospital in Ibadan, Nigeria. Afr J Med Med Sci 2003;32:349-52.
Ugboma HA, Onyearugha C. Stillbirths in a tertiary hospital, Niger delta area of Nigeria; less than a decade to the millennium developmental goals. Int J Trop Dis Health 2012;2:16-23.
Archibong EI, Sobande AA, Al-Bar HM, Asindi AA. Unattended delivery and perinatal outcome: a tertiary hospital experience. Nig J Paediatr 2002;29:66-70.
Etuk SJ, Etuk IS, Ekott MI, Udoma EJ. Perinatal outcome in pregnancies booked for prenatal clinic but delivered outside health care facilities in Calabar, Nigeria. Acta Trop 2000;75:29-33.
Eze JN, Egwuatu VE, Umeora OUJ, Esike COU, Onukwuli VO. Stillbirths at the Mater Misericordiae Hospital, Afikpo, Southeast Nigeria – a review. EMJ 2009;8:35-40.
Mela GS, El-Nafaty AU, Massa AA, Audu BM. Obstructed labour, a public health problem in Gombe, Gombe State, Nigeria. J Obstet Gynaecol 2003;23:369-73.
Kambarami RA. Levels and risk factors for mortality in infants with birth weights between 500 and 1,800 grams in a developing country: a hospital based study. Central Afr J Med 2002;48:133-6.
Langley FA. The perinatal post-mortem examination. J Clin Pathol 1971;24:159-69.
Bain AD. The perinatal autopsy. In: Cockburn F, Drillien CM, editors. Neonatal medicine. Oxford: Blackwell Scientific Publications; 1974. p. 820-34.
Potter EL, Craig JM. Post-mortem examination. In: Potter EL, Craig JM, editors. Pathology of the fetus and infant. 3rd ed. Chicago: Year Book Medical Publishers; 1975. p. 84-5.
Genest DR, Singer DB. Estimating the time of death in stillborn fetuses: III. External fetal examination; a study of 86 stillborn. Obstet Gynecol 1992;80:593-600.
Olusanya O, Okpere E, Ezimokhai M. The importance of social class in voluntary fertility control in a developing country. West Aft J Med 1985;4:205-12.
Suleiman BM, Ibrahim HM, Abdulkarim N. Determinants of stillbirths in Katsina, Nigeria: a hospital-based study. Pediatr Rep 2015;7:5615.
Drife JO. Perinatal audit in low- and high-income countries. Semin Fetal Neonatal Med 2006;11:29-36.
Forbes JF, Pickering RM. Influence of maternal age, parity and social class on perinatal mortality in Scotland: 1960-82. J Biosoc Sci 1985;17:339-49.
Jehan I, McClure E, Salat S, Rizvi S, Pasha O, Harris H et al.
Stillbirths in an urban community in Pakistan. Am J Obstet Gynecol 2007;197:257.e1-8.
Hossain N, Khan N, Khan NH. Obstetric causes of stillbirth at low socioeconomic settings. J Pak Med Assoc 2009;59:744-7.
Avachat SS, Phalke DB, Phalke VD. Risk factors associated with stillbirths in the rural area of Western Maharashtra, India. Arch Med Health Sci 2015;3:56-9. [Full text]
Vogel JP, Souza JP, Mori R, Morisaki N, Lumbiganon P, Laopaiboon M et al.
Maternal complications and perinatal mortality: findings of the World Health Organization Muticountry Survey on Maternal and newborn Health. BJOG 2014;121(Suppl1):76-88.
Gordon A, Greenow R, McGeechan K, Morris J, Jeffery H. Risk factors for antepartum stillbirth and the influence of maternal age in New South Wales Australia: a population based study. BMC Pregnancy Childbirth 2013;13:12.
Mondal D, Golloway TS, Bailey TC, Mathews F. Elevated risk of stillbirth in males: systematic review and meta-analysis of more than 30 million births. BMC Med 2014;12:220.
Lawn JE, Lawn AC, Kinney M, Sibley L, Carlo WA, Paul VK et al.
Two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done. Int J Gynaecol Obstet 2009;107(Suppl 1):S5-19.
Maclennan A. A template for defining a causal relation between acute intrapartum events and cerebral palsy: international consensus statement. BMJ 1999;319:1054-9.
Fawole AO, Shah A, Tongo O, Dara K, El-Ladan AM, Umezulike AC et al.
Determinants of perinatal mortality in Nigeria. Int J Gynaecol Obstet 2011;114:37-42.
Feresu SA, Harlow SD, Welch K, Gillespie BW. Incidence of stillbirth and perinatal mortality and their associated factors among women delivering at Harare Maternity Hospital, Zimbabwe: a cross-sectional retrospective analysis. BMC Pregnancy Childbirth 2005;5:9.
Umeora OUJ, Egwuatu VE. The role of unorthodox and traditional birth care in maternal mortality. Trop Doct 2010;40:13-7.
Gold KJ, Abdul-Mumin AR, Boggs ME, Opare-Addo HS, Lieberman RW. Assessment of “fresh” versus “macerated” as accurate markers of time since intrauterine fetal demise in low-income countries. Int J Gynaecol Obstet 2014;125:223-7.
Kandasamy Y, Kilcullen M, Watson D. Fetal autopsy and closing the gap. Aust NZ J Obstet Gynaecol 2016;56:252-4.
Burden C, Bradley S, Storey C, Ellis A, Haezel AE, Downe S et al.
From grief, guilt pain and stigma to hope and pride − a systematic review and meta-analysis of mixed-method research of the psychosocial impact of stillbirth. BMC Pregnancy Childbirth 2016;16:9.
[Table 1], [Table 2]