Introduction

The definition of a stillbirth varies across countries. The American College of Obstetricians and Genealogists define fetal demise as the death of a fetus past 20 weeks of gestation and or weight of 500 guns and above.1 In United Kingdom, stillbirth is defined as delivery of a baby with no signs of life after 24 weeks of Pregnancy.2 However for the purpose of statistics for international comparison, as per World Health Organization (WHO), stillbirth (SB) is the birth of a newborn after 28th completed week and weighing 1000gms or more when the baby does not breathe or show any sign of life after delivery, before onset of labor(antepartum death) or during labor (intra partum death).3 Stillbirth is a significant contributor to perinatal mortality in developing countries and it is a devastating experience for parents as well as obstetricians.

The objectives of this study were to know the prevalence and to identify the causes of stillbirths so that possible preventive measures can be suggested to decrease the rate of stillbirths.

Materials and Methods

This retrospective observational study was carried out from July 2018 to June 2019 at a tertiary care teaching hospital. Case Records were thoroughly analysed with respect to age, parity, history of stiibirth in previous pregnancy, gestational age, associated complicating factors like the hypertensive disorders of pregnancy, diabetes, severe anemia, etc. in addition to details of investigations that were carried out. Fetal characteristics were studied with respect to sex, birth weight and gross congenital anomalies. We have evaluated all cases of stillbirths using Relevant Condition at Death (ReCoDe) classification4 system to find out the causes of fetal loss which is a clinically based system appropriate for developing countries where only minimal investigations are possible. Mode of delivery and associated complications were also studied.

Results

During the study period, out of 6587 total births, there were 109 stillbirths. Hence prevalence of stillbirths in present study was 16.5 per 1000 total birth.

As shown in Table 1, majority of patients having stillbirths were in age group of 20-24 years (37.7%). The majority of patients having stillbirths were para three or more 57(52.2%). Illiterate patients were 17 (15.6%) whereas 57(52.2%) patients had primary education. Majority of patients were residing in urban area, 92(84.4%) and majority were unregistered patients 72(66%).

As shown, in Table 2, majority of SB 56 (51.4%) occurred between 32-37 weeks of gestational age and 88 (80.7%) were preterm, that is less than 37 weeks of gestational age.

The majority of patients 93(85.3%) delivered vaginally whereas 16(14.7%) required caesarean section.

As shown in Table 3, majority 49(45%) of stillborn fetus weighed from 1000-1499gm. Majority 65(59.6%) were male and 44(40.4%) were female. Only 17(15.6%) were macerated, compared to 92(84.4%) who were non-macerated.

Table 4, shows distribution of stillbirths according to Relevant Condition at Death (ReCoDe) classification. In present study, two most common reasons for stillbirths were hypertensive disorder of pregnancy and anaemia in 27 (24.8%) and 24(22%) of stillbirths respectively. Unexplained cause for stillbirth was found in 21 (19.2%) of patients. Accidental haemorrhage and placenta previa as a placental cause for stillbirths in 9 (8.2%) and placenta previa was seen in 3(2.8%) respectively. Intrauterine growth restriction (IUGR) and congenital anomaly as a fetal cause for stillbirths was present in 9(8.2%) and 3 (2.8%) respectively. Oligoamnions was present in 6 (5.5%) of patients.

Discussion

The definition of stillbirth recommended by WHO for international comparison is a baby born with no signs of life at or after 28 weeks gestation.3

In 2015 there were 2.6 million stillbirths globally, with more than 7178 deaths a day. The majority of these deaths occurred in developing countries. Ninety-eight percent occurred in low- and middle-income countries. The stillbirth rate in sub-Saharan Africa is approximately 10 times that of developed countries (29 vs. 3 per 1000 births). Worldwide, the number of stillbirths has declined by 19.4% between 2000 and 2015, representing an annual rate of reduction (ARR) of 2%. This reduction noted for stillbirths is lower than that noted for maternal mortality ratio (AAR=3.0%) and under 5 mortality rate (ARR= 3.9%), for the same period.3

Worldwide in 2015, 18.4 stillbirths per 1000 total births occurred, compared with 24.7 stillbirths in 2000. During the study period, out of 6587 total births, there were 109 stillbirths. Hence, proportion of stillbirths in our study was 16.5 per 1000 total birth. But it was still way above the World Health Assembly (WHA) endorsed target of 12 or fewer in all countries by 2030. Global ARR needs to more than double the present ARR of 2%v to accomplish the target for reduction in stillbirth. The Government of India has developed an Indian Newborn Action Plan that includes efforts to reduce stillbirths to < 10 per 1000 births by 2030.5

In present study, 9 (8.2%) patients were of below 20 years of age, 41 (37.7%) patients were between ages of 20-24 years, 36 (33%) were between ages of 25-29 years and elderly patient (>35 years) was 1 (0.9%). Mustufa MA et al6 has reported that, stillbirth were common (73.7%) in age group of 20-35 years. Njoku C.O et al7 stated that SB is common (33.7%) in age group of 30-34 years. Showghy et al8 stated that pregnancy at the age of 16 years and less than 16 years increase the risk of stillbirths by 4 times. Fretts RC et al9 has concluded that age of 35 and more can increase risk of foetus death by 1.5 times.

The parity of the patient influences pregnancy outcome. In present study, proportion of stillbirths was higher in multigravida 73(67%). Njoku C.O et al⁷ stated that proportion of stillbirths was higher in multigravida (82.1%) which is similar to our study whereas Mustufa MA et al 6 concluded that proportion of stillbirths was higher in primigravida patient (61%).

In present study, illiterate patients were 17 (15.5%) whereas 57(52.2%) patients had primary education. These findings surely point relation of education and health seeking behavior.

In present study, proportion of stillbirth was higher among 72 (66%) emergency admissions compared to 37 (34%) registered admissions. Lack of adequate antenatal care is the most important problem that needs urgent attention. If patient has taken adequate ANC then anemia, hypertensive disorders etc. can be diagnosed at earlier stages and managed. Hence, stillbirth due to these causes can be prevented. It is well-established that adequate ANC is associated with better pregnancy outcome. Al Kadri et al10 found that women who did not receive ANC are at 70% risk of Stillbirth. The majority of stillbirths are preventable, evidenced by the regional variation across the world. The rates correlate with access to maternal healthcare.3

Prematurity and Intrauterine growth retardation (IUGR) are another risk factors for fetal death. In present study, majority of stillbirth 56 (51.4%) occurred between 32-37 weeks of gestational age and 88 (80.7%) were preterm, that is less than 37 weeks of gestational age. Mustufa MA et al6 concluded that proportion of stillbirth was higher (55.47%) between 32-37 weeks of gestational age which is similar to our study.

In present study, majority 49(44.9%) of stillborn fetus weighed from 1000-1499gm. Birth weight is one of the significant factors for an adverse fetal outcome.11

In present study, out of all stillborn babies, 65(59.6%) were male and 44(40.4%) were female. A meta-analysis by Mondal D et al.,12 which includes data on more than 30 million births, links sex with stillbirth, the risk being about 10% higher in male fetuses. The reason for male preponderance is unclear but may be linked to the difference in male and female development. Male embryos have faster development and higher metabolic rates than female embryos and this potentially leave male fetuses more vulnerable to distress or death from a range of stressors including endocrine fluctuation, oxidative stress and faster nutritional depletion when they encountered stressful conditions.

The ReCoDe system4 of classification helped us to identify a cause in 80.8% of stillbirths. In present study, hypertensive disorders of pregnancy was cause of stillbirths in 27(24.8%). Njoku C.O et al7 reported 18.9% of stillbirths due to hypertensive disorders. Sharma S et al13 concluded that PIH accounted for 19.6% of stillbirths. In PIH, vasospasm decreases blood flow to all organs, particularly uteroplacental perfusion. So oxygen supply to fetus decreases and leads to fetal hypoxia and stillbirth.

In present study, stillbirth occured due to anemia in 24(22%) compared to 12.2% reported by Njoku C.O et al.7 Stillbirth due to Iron deficiency is the most common cause of anaemia in pregnancy and Iron and folic acid supplements are recommended for prevention.14

In present study, accidental haemorrhage and placenta previa as a placental cause for stillbirths in 9 (8.2%) and in 3(2.8%) respectively. Njoku C.O et al7 reported that abruptio placenta and placenta previa accounted for 9.3% and 2.2% cases of stillbirth. Sharma S et al 13 reported antepartum haemorrhage in 12% as a cause of stillbirth. Antepartum haemorrhage leads to maternal blood loss leading to hypovolemic anaemia, hypoxia, hypertonic uterine contraction causes fetal hypoxia and death.

In present study, congenital malformation in form of neural tube defect leading to stillbirth in 3(2.7%). Njoku C.O et al7 reported stillbirth due to congenital malformation in 1% while Sharma S et al13 reported stillbirth due to congenital malformation in 8%.

In present study, other maternal conditions like fever, gestational diabetes, hypothyroidism accounted for stillbirth in 03 (2.7%), 02 (1.8%), 02 (1.8%) respectively.

In present study, normal vaginal delivery occurred in 93 (85.3%), while operative procedure was required in 16 (14.7%) cases. Njoku C.O et al 7 reported that normal vaginal delivery occurred in 74.3% patients of stillbirth while operative procedure was needed in 25.7%.

Most common complication associated with stillbirth was DIC that occurred in 4(3.6%). Thromboplastin released from blood clots damages placenta and dead fetus activates coagulation cascade that leads to DIC. These patients were managed by treatment of underlying condition, maintaining perfusion to vital organs, transfusion of blood and blood components. Availability of multispecialty and intensive care helps in management of these patients. Stillbirth resulted due to uterine rupture in 01 (0.9%) patient who had history of previous two caesarean section.

In present study, unexplained stillbirth occurred in 21 (19.2%). Which is comparable to Njoku C.O et al7 (20.8%).

Conclusion

Majority of patients were unregistered and had not taken antenatal care or had inadequate antenatal care. The new ReCoDe primary classification system helped us in assigning the probable cause of stillbirth in majority of patients. Hypertensive disorders during pregnancy were the leading cause for stillbirth followed by anaemia and unexplained causes. A significant proportion of stillbirths can be prevented by health education regarding importance of adequate antenatal care, warning signs and institutional deliveries. Adequate antenatal and intra natal care can prevent stillbirths due to modifiable risk factors such as pre-eclampsia, eclampsia, anemia, diabetes etc. Timely reference to higher center is also necessary. Emotional support and counseling of patients and her relatives are very much essential in patients having stillbirth. In case of unexplained stillbirth, fetal autopsy, placental and membrane examination can be helpful for finding out causes and to plan future pregnancy accordingly.

Source of Funding

None.

Conflict of interest

None declared.