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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 3  |  Issue : 1  |  Page : 56-59

Risk factors associated with stillbirths in the rural area of Western Maharashtra, India


1 Department of Community Medicine, Padmashri Vithhalrao Vikhe Patil Medical College, Ahmednagar, Maharashtra, India
2 Department of Community Medicine, Rural Medical College, Loni, Maharashtra, India

Date of Web Publication13-Apr-2015

Correspondence Address:
Dr. Shubhada Sunil Avachat
Department of Community Medicine, Padmashri Vithhalrao Vikhe Patil Medical College, Ahmednagar - 414 003, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2321-4848.154946

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  Abstract 

Background: Overall perinatal mortality rates have fallen considerably in the past several decades but fetal deaths have not decreased as rapidly as the neonatal portion. In 2009, two-third of the stillbirths in the world occurred in South Asia and sub-Saharan Africa and 55% stillbirths occurred in rural families from these regions. Knowledge of the relative importance of the different causes of stillbirth and neonatal deaths in developing countries is still lacking. Objective: A retrospective to assess the extent of stillbirths in a teaching hospital located in rural area. To study various causative and contributing factors for stillbirths. Materials and Methods: All the case records of the deliveries occurred in the study setting during study period (April 2009 to March 2010) were evaluated with the help of a predesigned proforma. Total 3,458 deliveries occurred, of them 141 were stillbirths. Results: Total 75.6% stillbirths occurred to the women in the age group of 20-35 years. Most of the stillbirths were preterm (67.3%) as compared to term or post-date deliveries. Significant association was observed between gestational age and stillbirth. Total 82 (58.15%) babies had low birth weight. Maternal factors were responsible for majority of stillbirths (53.19%) while 34% stillbirths were idiopathic. Conclusion: More than half of the stillbirths were associated with maternal factors like pregnancy-induced hypertension, antepartum hemorrhage and anemia. Improvement in availing essential obstetric care can reduce the magnitude of stillbirths.

Keywords: Causes, rural area, risk factors, stillbirths


How to cite this article:
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

How to cite this URL:
Avachat SS, Phalke DB, Phalke VD. Risk factors associated with stillbirths in the rural area of Western Maharashtra, India. Arch Med Health Sci [serial online] 2015 [cited 2019 Sep 16];3:56-9. Available from: http://www.amhsjournal.org/text.asp?2015/3/1/56/154946


  Introduction Top


Perinatal deaths are responsible for about 7% of the total global burden of diseases and there is a wide disparity of perinatal mortality among the developed and developing countries. Of the 4 million neonatal deaths that occur every year, 98% deaths occur in the poorest countries of the world. This figure seems even more catastrophic when seen in the light of the estimate that for every neonatal death, there is one stillbirth. [1] Although overall perinatal mortality rates have fallen considerably in the past several decades, fetal deaths have not decreased as rapidly as the neonatal portion. [2],[3] Globally there were 2.64 million stillbirths in 2009 with more than 8,200 deaths per day; two-third of these deaths were from South Asia and sub-Saharan Africa and 55% stillbirths occurred in rural families from these regions. [4]

It is estimated that some 1.8 million stillbirths occur in 10 countries and India is one of them.

The rates also vary widely within countries. In India, rates range from 20 to 66 per 1,000 births in different states. [5]

Despite efforts to identify the etiologic factors contributing to fetal death, a substantial portion of fetal deaths are still classified as unexplained intrauterine fetal demise. This proportion of unexplained deaths has remained fairly constant over the decades. These deaths are therefore difficult to prevent because the determinants have not been adequately identified. Even in cases in which a cause of death can be determined, the lack of uniformity in data collection and classification of causes of fetal death have made comparisons and accurate reporting difficult. [6]

Stillbirths represent a devastating pregnancy outcome and there is a need for increased efforts to identify the causes and to implement preventive measures. Knowledge of the relative importance of the different causes of stillbirth and neonatal deaths in developing countries is still lacking. A detailed study of the causes of stillbirths in a rural community with a view to identifying possible interventions within the available resources are essential. Therefore, the present study was conducted to assess the extent of stillbirths and to study various maternal, fetal factors influencing occurrence of stillbirths in a teaching hospital in rural area.


  Materials and Methods Top


Study design and setting- A retrospective study was conducted in a teaching hospital (Medical college hospital) in rural area of western Maharashtra, India.

Sampling technique and sample size

All the deliveries conducted from 1st April 2009 to 31st March were included and assessed. Total 3,458 deliveries occurred during the study period.

Data collection

After obtaining ethical clearance from institutional ethical committee, this observational record-based study was conducted. The case records of all deliveries conducted during study period were assessed to find out the number of stillbirths. Case records of the stillbirths were studied in detail to assess influencing factors viz., age of the mother, parity, gestational age and birth weight of the fetus etc., with the help of a predesigned proforma.

Case definition

The World Health Organization (WHO) defines stillbirth as a "fetal death late in pregnancy" and allows each country to define the gestational age at which a fetal death is considered a stillbirth for reporting purposes; in India, death of a fetus weighing 1,000 g or more than 28 weeks of gestation is defined as stillbirth. [7],[8]

Cause of death assignment was made in accordance with a modified version of the classification system proposed by Baird et al. and Pattinson et al. who adapted the system for use in developing country settings allowing for the identification of the following primary obstetrics causes of death: Spontaneous preterm labor (<37 weeks), infections, antepartum hemorrhage, intrauterine growth restriction, hypertension, fetal abnormality, trauma and intrapartum asphyxia, maternal disease, other unexplained intrauterine death and multiple pregnancy. [9],[10]

Statistical study

Data were tabulated and analyzed as percentages and proportions. Chi-square test was used as a test of significance to test the association.


  Results Top


A total of 3,458 deliveries occurred in the study setting (medical college hospital in rural area) during the study period. Out of them, 141 were still births. The stillbirth rate in our study was 40/1000 live births.

Majority of stillbirths, 107 (75.6%), occurred to the women in the age group of 20-35 years; however, no significant association was observed. Most of the stillbirths were preterm (67.3%) as compared to term or post-date deliveries [Table 1]. Significant association was observed between gestational age and stillbirth (P < 0.001).
Table 1: Maternal and obstetric factors and stillbirths


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As revealed in [Table 2] of the 141 stillbirths, 82 (58.15%) babies had low birth weight and 29% had very low birth weight.
Table 2: Birth weight and stillbirths


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Maternal factors were responsible for the majority of stillbirths (53.19%) while 34% stillbirths were idiopathic. Among the maternal factors, pregnancy-induced hypertension was the commonest cause followed by antepartum hemorrhage, while congenital anomaly (66.6%) was the most common fetal factor responsible for stillbirth. Placental insufficiency was responsible for 12 (8.5%) stillbirths.

Total 89.36% stillbirths had vertex presentation, 7.8% had breech presentation and 2.8% had transverse lie. Majority of the stillborn babies (60.13%) were born to mothers having anemia.


  Discussion Top


A better knowledge and understanding of the etiology of stillbirth is imperative to achieve decrease in stillbirth rate by proper health planning.

Comparing the results of the present study with other studies conducted in different settings in India and other developing countries revealed the following similarities and differences.

As observed in [Table 3] and [Table 4], stillbirth rate is quite high in rural areas of developing countries. In the present study too, 141 (4%) stillbirths occurred during the study period. Similar to our study in other studies conducted in developing countries, the stillbirth rate was 4% in Uttar Pradesh, 5.6% in Zimbabwe and 2.13% in Nepal. [11],[12],[13]
Table 3: Causal factors of stillbirths


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Table 4: Obstetric causes of stillbirths


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Majority of stillbirths (75.6%) in the present study occurred among mothers in the age group of 25-34 years. Similar finding was observed by Nayak et al. in India and in other studies conducted in Iran and Zimbabwe. [6],[12],[14]

The stillborn babies were generally born at an earlier gestational age, as would be expected; in our study too, stillbirths were significantly more in babies born with <37 weeks of gestation similar to other studies. [6],[13],[15] However, most of the stillbirths occurred in 37-40 weeks of gestational age in a study conducted by Singh et al.[11]

Slightly higher proportion of stillbirths (38.29%) occurred to primiparous women; however, there was no significant association found between parity and occurrence of stillbirths. Similar finding was observed by Lucy et al. and Fredrick et al. in their studies conducted in U.K. and Norway. [15],[16] However, stillbirths were more common among primipara in the studies conducted by Nayak et al. and Huang et al.[14],[17]

Maternal risk factors were the most common cause of stillbirths; however, 34.05% stillbirths were idiopathic. Pregnancy-induced hypertension is the most common cause of stillbirth in our study followed by antepartum hemorrhage, while congenital anomaly was the commonest fetal factor associated with stillbirth. Similar to this study, pregnancy-induced hypertension was the most common risk factor in other studies conducted in India, Pakistan, Brazil and other countries. [11],[14],[17],[18],[19]


  Conclusion Top


The stillbirth rate is quite high in rural area of developing countries. More than half of the stillbirths were associated with maternal factors like pregnancy-induced hypertension, antepartum hemorrhage and anemia. But due to lack of awareness, ignorance and access, there is no proper utilization of essential obstetric care in rural areas. Improvement in availing essential obstetric care can reduce the magnitude of stillbirths.

 
  References Top

1.
Moss W, Darmstadt GL, Marsh DR, Black RE, Santosham M. Research priorities for the reduction of perinatal and neonatal morbidity and mortality in developing country communities. J Perinatol 2002;22:484-95.  Back to cited text no. 1
    
2.
Zhang J, Cai W. Risk factors with ante partum foetal death. Early Hum Dev 1992;28:193-200.  Back to cited text no. 2
    
3.
Hyattsville, Maryland, Centre for Health Statistics. Vital and health statistics of the United States. Vol II. Mortality. Part A, section 3. Fetal Mortality; 1968-1988.  Back to cited text no. 3
    
4.
Available from: http://www.who.int/maternal_child_adoloscent/epidemiology/stillbirth [Last cited on 2013 Oct 24].  Back to cited text no. 4
    
5.
Cousens S, Blencowe H, Stanton C, Chou D, Ahmed S, Steinhardt L, et al. National, regional and worldwide estimates of stillbirth rates in 2009 with trends since 1995: A systematic analysis. Lancet 2011;377:1319-30.  Back to cited text no. 5
    
6.
Jahanfar SH, Ghiyasi P, Haghani H. Risk factors related to intra uterine fetal death in Iran, A case-control study. Shiraz E-Med J 2005;6:3-4.  Back to cited text no. 6
    
7.
World Health Organization. Definitions and indicators in Family Planning Maternal and Child Health and Reproductive Health. Geneva: WHO Press; 2001.  Back to cited text no. 7
    
8.
Park K. Park′s textbook of Preventive and Social Medicine. Editor J Park, edition of textbook 22 nd ed. Jabalpur: Bhanot Publishers; 2013. p. 521.  Back to cited text no. 8
    
9.
Pattinson RC, De Jong G, Theron GB. Primary causes of total perinatally related wastage at Tygerberg Hospital. S Afr Med J 1989;75:50-3.  Back to cited text no. 9
    
10.
Baird D, Walker JR, Thomson AM. The causes and preventions of stillbirths and first week deaths. J Obstet Gynaecol Br Emp 1954;61:433-48.  Back to cited text no. 10
    
11.
Singh N, Pandey K, Gupta N, Arya AK, Pratap C, Naik R. A retrospective study of 296 cases of intra uterine fetal deaths at a tertiary care centre. Int J Reprod Contracept Obstet Gynecol 2013;2:141-6.  Back to cited text no. 11
    
12.
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.  Back to cited text no. 12
    
13.
Tamrakar SR, Chawala CD. Intrauterine foetal death and its probable causes: Two years experience in Dhulikhel Hospital - Kathmandu University Hospital. Kathmandu Univ Med J (KUMJ) 2012;10:44-8.  Back to cited text no. 13
    
14.
Nayak S, Garg N. Determinants of antepatum fetal death. J Obstret Gynaecol India 2010;60:484-97.  Back to cited text no. 14
    
15.
Savvas E, Evangelos A, Lucy K, David L, Toby F. Case-control study of factors associated with intrauterine fetal deaths. Med Gen Med 2004;6:53.  Back to cited text no. 15
    
16.
Frøen JF, Arnestad M, Frey K, Vege A, Saugstad OD, Stray-Pedersen B. Risk factors for sudden intrauterine death: Epidemiologic characteristics of singleton cases in Oslo, Norway. Am J Obstet Gynecol 2001;184:694-701.  Back to cited text no. 16
    
17.
Huang DY, Usher RH, Kramer MS, Yang H, Morin L, Fretts RC. Determinants of unexplained antepartum deaths. Obstet Gynecol 2000;95:215-21.  Back to cited text no. 17
    
18.
Márcia M, José G, Coríntio M. Risk factors associated to fetal deaths. Sao Paulo Med J 1998;116.  Back to cited text no. 18
    
19.
Korejor R, Bhutta S, Noormi J. An audit and trends of perinatal mortality at Jinnah Postgraduate medical center, Karachi. J Pak Med Assoc 2007;57:168-72.  Back to cited text no. 19
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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