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Stillbirth rate at an emerging tertiary health institution in Enugu, southeast Nigeria
International Journal of Gynecology and Obstetrics 115 (2011) 164–166
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
CLINICAL ARTICLE
Stillbirth rate at an emerging tertiary health institution in Enugu, southeast Nigeria Euzebus C. Ezugwu a,⁎, Hyacinth E. Onah a, Hygenius U. Ezegwui a, Chidi Nnaji b a b
Department of Obstetrics/Gynecology, University of Nigeria Teaching Hospital, Itukku-Ozalla, Enugu, Nigeria Department of Obstetrics/Gynecology, Enugu State University of Science and Technology Teaching Hospital, Parklane, Enugu, Nigeria
a r t i c l e
i n f o
Article history: Received 15 March 2011 Received in revised form 22 May 2011 Accepted 26 July 2011 Keywords: Nigeria Stillbirth Tertiary health institution
a b s t r a c t Objectives: To determine the stillbirth rate and factors predisposing to a stillbirth delivery at a teaching hospital in Nigeria, with the aim of identifying solutions. Method: A descriptive study of all stillbirths delivered at Enugu State University of Science and Technology Teaching Hospital, Parklane, Nigeria between January 1 and December 31, 2009. The sociodemographic characteristics of the mothers were documented and the possible causes of death were analyzed. Results: There were 153 stillbirths and 2064 total deliveries, giving a stillbirth rate of 74 per 1000 deliveries. Of the stillbirths, 52.3% were fresh and 47.7% were macerated. Women who had not received prenatal care had a significantly higher stillbirth rate (P b 0.05). The most likely cause of a macerated stillbirth was a hypertensive disorder of pregnancy, whereas the likely causes of fresh stillbirths were labor-related. The “3 levels of delay” and injudicious use of oxytocin in labor contributed to the intrapartum stillbirths (P b 0.05). Conclusion: The stillbirth rate recorded in the study institution is unacceptably high. Appropriate prenatal care, timely intervention, and prompt and appropriate intrapartum care are key to achieving a reduction in the stillbirth rate. © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction It is estimated that over 3.2 million stillbirths occur worldwide each year, with the incidence rate being highest in Sub-Saharan Africa. The majority (98%) of stillbirths occur in low- and middle-income countries [1,2]. The estimated annual number of stillbirths globally (3.2 million) is close to the total number of neonatal deaths (3.8 million) [3], and approximates the total number of childhood deaths between the ages of 1 and 5 years [1]. Globally, approximately 1 million intrapartum stillbirths occur and this number exceeds that of child deaths attributable to malaria (820 000) [4]; as such, it deserves commensurate attention and investment. Stillbirth, like any child death, is a source of grief and sorrow to the affected family and may lead to long-term psychological problems [5,6]. Just like the maternal mortality rate, the stillbirth rate has been used as an indicator of the quality of obstetric care, with a high stillbirth rate usually seen in areas with a high maternal mortality rate and a low stillbirth rate in countries with low maternal mortality rates [7]. Stillbirths occurring prenatally (fetal death before the onset of labor) account for two-thirds to three-quarters of all stillbirths globally, whereas the remaining stillbirths are largely associated with complications of labor and/or inadequate care during labor and delivery [7]. The reverse is the case in low-income countries, where a significant proportion of ⁎ Corresponding author at: Department of Obstetrics/Gynecology, University of Nigeria Teaching Hospital, PMB 01129, Itukku-Ozalla, Enugu 234, Nigeria. Tel.: + 234 80 37020 295; fax: + 234 042 252665. E-mail address: [email protected] (E.C. Ezugwu).
stillbirths occur intrapartum resulting in fresh stillbirths. This is a reflection of poor access to and/or poor quality of intrapartum care. The quality of care during the prenatal period directly affects the incidence of prenatal (macerated) stillbirths [8]. Risk factors present during the prenatal period should be identified and properly managed. The perinatal mortality rate is globally accepted as an indicator of the quality of obstetric and neonatal care. With 39 stillbirths and neonatal deaths (occurring in the first week of life) per 1000 pregnancies [9], the perinatal mortality rate in Nigeria is unacceptably high, as it is in many low-income countries. Stillbirths account for approximately 62% of perinatal deaths in West Africa [10], and approximately 60% of stillbirths are intrapartum-related [11] and largely preventable. The majority of infants that survive a severe intrapartum insult and are born alive die shortly afterwards. Some 78%–90% of intrapartum-related neonatal deaths occur within the first 48 hours of birth and nearly all occur within the first week of life [12]. The present study aimed to determine the incidence rate of stillbirths at Enugu State University of Science and Technology Teaching Hospital (ESUTTH), Parklane, Nigeria, and to identify the likely causes and events that may have contributed to the stillbirths with a view to suggesting interventions that will lead to their reduction. The focus is on preventing intrapartum-related stillbirths and neonatal deaths in low-resource countries. This is the first such study on this subject conducted at ESUTTH. 2. Materials and methods The present study is a descriptive study of all stillbirths delivered at ESUTTH between January 1 and December 31, 2009. The teaching
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.05.028
E.C. Ezugwu et al. / International Journal of Gynecology and Obstetrics 115 (2011) 164–166
hospital is a tertiary health facility and a referral center. It is located in Enugu, the capital of Enugu State in southeastern Nigeria. The hospital serves an estimated 6 million people from Enugu State and the neighboring states. It was a general hospital until November 2003, when it was upgraded to become a specialist hospital, and in June 2006 it was again upgraded to become a teaching hospital. The data for the present study were collected prospectively, with cases of fetal death reviewed on a daily basis as they occurred. For every case of stillbirth included in the study, 2 successive women with normal live births were recruited into a comparison group. To enable international comparison, a stillbirth was defined according to the WHO International Classification of Diseases (ICD10) [13] as an infant born after 28 completed weeks of gestation with no heartbeat, even after resuscitation, and a birth weight of 1000 g or more. Intrapartum stillbirths are generally normal in appearance at delivery, with no sign of skin disintegration, and are often called fresh stillbirths. When the skin is not intact, it is referred to as macerated, implying that death occurred more than 12 hours before delivery [21]. Using a prepared pro forma, the sociodemographic characteristics of the mothers were recorded. All mothers who had an intrapartum stillbirth were also interviewed. The relevant condition at death (ReCoDe) classification system [14] was used to identify the most likely causes of macerated stillbirths, and all cases of intrapartum stillbirth were critically reviewed to determine any associated events. The results were analyzed using the statistical software Epi Info version 3.3.2 (Centers for Disease Control and Prevention, Atlanta, GA, USA). P b 0.05 was considered statistically significant. No autopsies could be performed because the parents declined consent, despite appropriate counseling. The study was approved by the Ethics Committee of the study hospital.
3. Results During the 12-month study period, there were 2064 deliveries; 153 of these were stillbirths, giving a stillbirth rate of 74 per 1000 deliveries. Eighty (52.3%) stillbirths were fresh (intrapartum) stillbirths and 73 (47.7%) were macerated stillbirths. The intrapartum stillbirth rate was 39 per 1000 births. Of the intrapartum stillbirths, 43 (53.2%) occurred prior to presentation at the hospital as evidenced by an absence of the fetal heartbeat at presentation. Women who had not received prenatal care had a significantly higher stillbirth risk (odds ratio 1.56; P = 0.04). Age and parity of the mothers with stillbirths did not differ significantly from those with live births (Table 1). The most common likely cause of fetal death in the macerated stillbirth group was hypertensive disease in pregnancy (Table 2). Events that were significantly more common in the intrapartum stillbirth group included 3 levels of delay in obtaining obstetric care, injudicious use of oxytocin in labor, and inadequate intrapartum monitoring (Table 3). Of the 20 women referred to the hospital with a history of an intrapartum bolus injection of oxytocin, 15 (83.3%) experienced uterine rupture and fetal death.
Table 1 Age and parity at delivery.a Characteristic Age, y ≤19 20–39 ≥40 Parity 0 1–4 ≥5 a
Stillbirth group (n = 153)
Control group (n = 306)
P value
15 (9.8) 129 (84.3) 9 (5.9)
22 (7.2) 275 (89.9) 9 (2.9)
0.36 0.09 0.13
31 (20.3) 95 (62.1) 27 (17.6)
76 (24.8) 185 (60.5) 50 (16.3)
0.29 0.54 0.74
Values are given as number (percentage) unless otherwise indicated.
165
Table 2 Causes of macerated stillbirth according to the relevant condition at death (ReCoDe) classification system.a,b Classification
Occurrence in the macerated stillbirth group (n = 97)
Conditions affecting the mother Hypertensive disorders of pregnancy Diabetes mellitus Repeated intake of traditional medicines Severe anemia (hemoglobin b 6 g/dL) Febrile condition preceding stillbirth HIV/AIDS No relevant condition identified Conditions affecting the fetus Congenital anomaly (anencephaly) a b
30 (30.9) 3 (3.1) 8 (8.2) 15 (15.5) 27 (27.8) 4 (4.1) 8 (8.2) 2 (2.1)
Values are given as number (percentage). In some instances, there was more than 1 likely cause of death.
4. Discussion The overall stillbirth rate of 74 per 1000 births recorded in the present institution is unacceptably high. It is twice the estimated value of 32 per 1000 births reported for Sub-Saharan Africa and South Asia, and almost 15 times higher than the rate of 5 stillbirths per 1000 births in high-income countries [1]. The present rate is slightly lower than the rate of 89 stillbirths per 1000 births reported previously for Enugu [15]. Comparably high stillbirth rates have also been reported for other parts of Nigeria, specifically for Ogun (88 stillbirths per 1000 births) [16] and for Lagos (127 stillbirths per 1000 births [adjusted rate]) [17]. Furthermore, a significant proportion of stillbirths remain unrecorded. In Nigeria, nearly two-thirds (62%) of all deliveries occur at home [9] and pregnancies resulting in stillbirth among this group are usually not captured. The actual stillbirth rate in Nigeria, as in other low-income countries, may therefore be even greater than the reported rate because reported rates are usually derived from hospital data. This supports the need for a community-based study. The wide gap between the stillbirth rates in high-income countries and those in economically deprived countries is a reflection of the disparity in access to health care and healthcare quality between the two settings. Such a disparity may also occur within countries [6]. The nearly 10-fold reduction in the rate of stillbirths in highincome countries over the last 40–50 years—from 50 per 1000 births to less than 5 per 1000 births—has been heralded as one of the success stories of modern obstetrics in those countries [18]. This reduction is certainly related to the almost universal availability of, and accessibility to, prenatal and intrapartum care services that focus on prompt risk identification and reduction [1]. In the present study, the majority of stillbirths occurred among women who had not received prenatal care. Prenatal care is a key factor in reducing the stillbirth rate [19,20]. Many of the causes of prenatal stillbirth are potentially preventable, treatable, or modifiable Table 3 Factors potentially contributing to the occurrence of an intrapartum stillbirth.a,b Events
Intrapartum stillbirth group (n = 80)
Control group (n = 160)
P value
Delay in seeking care Delay in transfer from the referral center Delay in receiving care at the hospital d Bolus injection of oxytocin at the referral center Inadequate intrapartum monitoring Wrong diagnosis
36 10 15 18
(45.0%) (12.5%) (18.8%) (22.5%)
6 (3.8%) 3 (1.9%) 4 (2.5%) 2 (1.3%)
0.001 0.0012 0.0001 0.0001
8 (10.0%) 4 (5.0%)
3 (1.9%) 0 (0.0%)
0.0075 0.0117
a b c d
Values are given as number (percentage) unless otherwise indicated. Some cases had more than 1 contributing event. Fisher exact test. Decision–intervention interval at least 1 hour.
c
166
E.C. Ezugwu et al. / International Journal of Gynecology and Obstetrics 115 (2011) 164–166
[21]. Common causes of prenatal stillbirth in the present study were hypertensive disorders of pregnancy, febrile conditions, and severe anemia in pregnancy. With good prenatal care, the majority of these deaths could have been prevented. In a recent demographic and health survey in Nigeria, 36% of the women had not received any prenatal care [9]. Efforts should be geared toward providing universal access to prenatal care. The intrapartum stillbirth rate in the present study was 39/1000 births, with intrapartum stillbirths constituting 52.3% of the overall stillbirth rate. This figure is 5 times higher than the 10% rate expected for settings with optimal intrapartum care [2]. Such a high rate is unacceptable and a clear indication of suboptimal intrapartum care and/or poor access to care. A recent report from a sister institution in Enugu also described a high intrapartum stillbirth rate (52.1 per 1000 births) [15]. The rate of intrapartum stillbirths is highest in West Africa and in South Asian countries with challenging geographic barriers and low access to skilled care [22]. A significant proportion of the women who had a stillbirth did not have access to quality care because of cost barriers. Financial incapacity is one of the main reasons why women in low-income countries do not access care at a health facility even when they are aware of the benefits [23]. Some of these women resort to prayer houses, traditional birth attendants, or unregistered nursing homes staffed by unskilled birth attendants. Seriously unwell women who may have been badly managed at one of these centers are advised to go to a hospital. The present study identified several events that contributed significantly to the occurrence of intrapartum stillbirth. The 3 levels of delay observed in the present study are the same delays that have previously been shown to be major contributors to maternal mortality in Sub-Saharan Africa [24]. They include delays in seeking appropriate care (level-1 delay) because of financial challenges, and delays in transporting women with emergency obstetric complications to the hospital (level-2 delay). Although the present government is making efforts to bring health facilities with emergency obstetric care closer to the people, the pace is worrisome. Many women face substantial barriers to access emergency obstetric care because of the poor transportation infrastructure (bad roads) and challenging security issues. Another significant contributory event to intrapartum stillbirth observed in the present study was the injudicious administration of bolus oxytocin to expedite labor at maternity homes and prayer houses. This calls for training and retraining of nurses and midwifes in maternity homes and supports a call for closure of all unregistered delivery facilities. All maternity homes must be supervised and properly regulated by regulatory agencies constituted by the government. Institutional delays (level-3 delays, evidenced by the prolonged decision–intervention interval) also contributed significantly to the occurrence of intrapartum stillbirths, as has been reported previously [25,26], and this must be addressed. These delays consisted mainly of time spent waiting for the anesthetist and senior obstetrician to arrive for the emergency cesarean delivery and delays in the process of securing blood and other items that are required for emergency operations. Although the hospital is expected to provide all items necessary for an emergency cesarean delivery, the “out-of-stock syndrome” in the present hospital, as in many hospitals in low-income countries, is a big challenge. If an item is unavailable at the hospital, it is up to the patient's relatives to procure it, often at odd hours. The need to reduce the rate of intrapartum stillbirths calls for adequate intrapartum monitoring, and prompt and timely intervention in obstetric emergencies. To achieve this, a multifaceted approach is required that will remove all barriers to access to emergency obstetric care, implement a system of prompt and early referral, and improve transportation. The concepts of birth readiness and emergency preparedness should be encouraged. Stillbirth is a global problem that is admittedly worse in lowincome countries. Its reduction deserves as much attention as the reductions of neonatal mortality and under-5 mortality, which are
both Millennium Development Goal indicators. Therefore, we recommend a holistic and multidisciplinary approach that will empower women economically to eliminate the cost barrier to access to care, that will take health facilities closer to the people, and that will encourage an efficient and effective referral system. The aim should be to achieve optimal intrapartum monitoring as well as appropriate and timely intervention when required. There should be regular workshops, and training and retraining of service providers at all levels. Emergency drills may help define and test protocols for the management of obstetric emergencies. Conflict of interest The authors have no conflicts of interest. References [1] Stanton C, Lawn JE, Rahman H, Wilczynska-Ketende K, Hill K. Stillbirth rates: delivering estimates in 190 countries. Lancet 2006;367(9521):1487–94. [2] WHO. Neonatal and Perinatal Mortality. www.who.int. http://www.who.int/ making_pregnancy_safer/publications/neonatal.pdf. Published 2006. [3] UNICEF. State of the World's Children 2009: Maternal and Newborn Health. www. unicef.org. http://www.unicef.org/publications/index_47127.html. Published 2009. [4] UNICEF. The State of the World's Children 2009. www.unicef.org. http://www. unicef.org/sowc09/docs/SOWC09-FullReport-EN.pdf. Published 2009. [5] Samuelsson M, Rådestad I, Segesten K. A waste of life: fathers' experience of losing a child before birth. Birth 2001;28(2):124–30. [6] Trulsson O, Rådestad I. The silent child – mothers’ experiences before, during, and after stillbirth. Birth 2004;31(3):189–95. [7] Di Mario S, Say L, Lincetto O. Risk factors for stillbirth in developing countries: a systematic review of the literature. Sex Transm Dis 2007;34(7 Suppl):S11–21. [8] Yakoob MY, Menezes EV, Soomro T, Haws RA, Darmstadt GL, Bhutta ZA. Reducing stillbirths: behavioural and nutritional interventions before and during pregnancy. BMC Pregnancy Childbirth 2009;9(Suppl 1):S3. [9] National Population Commission Federal Republic of Nigeria. Nigeria Demographic and Health Survey 2008. www.nih.gov. http://www.ncbi.nlm.nih.gov/pubmed? term=Reducing%20stillbirths%3A%20Behavioural%20and%20nutritional% 20interventions%20before%20and%20during%20pregnancy. Published 2008. [10] Chalumeau M, Bouvier-Colle MH, Breart G, MOMA Group. Can clinical risk factors for late stillbirth in West Africa be detected during antenatal care or only during labour? Int J Epidemiol 2002;31(3):661–8. [11] Künzel W, Herrero J, Onwuhafua P, Staub T, Hornung C. Maternal and perinatal health in Mali, Togo and Nigeria. Eur J Obstet Gynecol Reprod Biol 1996;69(1):11–7. [12] Baqui AH, Darmstadt GL, Williams EK, Kumar V, Kiran TU, Panwar D, et al. Rates, timing and causes of neonatal deaths in rural India: implications for neonatal health programmes. Bull World Health Organ 2006;84(9):706–13. [13] WHO. International Statistical Classification of Diseases and Related Health Problems (ICD-10) in Occupational Health. WHO; 2004. 10th Revision. [14] Gardosi J, Kady SM, McGeown P, Francis A, Tonks A. Classification of stillbirth by relevant condition at death (ReCoDe): population based cohort study. BMJ 2005;331(7525):1113–7. [15] Chigbu CO, Okezie OA, Odugu BU. Intrapartum stillbirth in a Nigerian tertiary hospital setting. Int J Gynecol Obstet 2009;104(1):18–21. [16] Njokanma OF, Sule-Odu AO, Akesode FA. Perinatal mortality at the Ogun State University Teaching Hospital, Sagamu, Nigeria. J Trop Pediatr 1994;40(2):78–81. [17] Olusanya BO, Solanke OA. Predictors of term stillbirths in an inner-city maternity hospital in Lagos, Nigeria. Acta Obstet Gynecol Scand 2009;88(11):1243–51. [18] Goldenberg RL, Kirby R, Culhane JF. Stillbirth: a review. J Matern Fetal Neonatal Med 2004;16(2):79–94. [19] Dasgupta S, Saha I, Mandal AK. A study on profile of stillbirths. J Indian Med Assoc 1997;95(6):175 178. [20] Goldenberg RL, McClure EM, Belizán JM. Commentary: reducing the world's stillbirths. BMC Pregnancy Childbirth 2009;9(Suppl 1):S1. [21] Lawn J, Shibuya K, Stein C. No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths. Bull World Health Organ 2005;83(6):409–17. [22] Lawn JE, Lee 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 Gynecol Obstet 2009;107(Suppl 1):S5–S18 S19. [23] Islam M, Yoshida S. Women are still deprived of access to lifesaving essential and emergency obstetric care. Int J Gynecol Obstet 2009;106(2):120–4. [24] Harrison KA, Lister UG, Rossiter CE, Chong H. Perinatal mortality. In: Harrison KA, editor. Childbearing, health and social priorities—a survey of 22 774 consecutive hospital births in Zaria, Northern Nigeria, 92(Suppl 5). Br J Obstet Gynecol; 1985. p. 1–119. [25] Onah HE, Okaro JM, Umeh U, Chigbu CO. Maternal mortality in health institutions with emergency obstetric care facilities in Enugu State, Nigeria. J Obstet Gynecol 2005;25(6):569–74. [26] Onah HE, Ibeziako N, Umezulike AC, Effetie ER, Ogbuokiri CM. Decision - delivery interval and perinatal outcome in emergency caesarean sections. J Obstet Gynecol 2005;25(4):342–6.
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / i j g o
CLINICAL ARTICLE
Stillbirth rate at an emerging tertiary health institution in Enugu, southeast Nigeria Euzebus C. Ezugwu a,⁎, Hyacinth E. Onah a, Hygenius U. Ezegwui a, Chidi Nnaji b a b
Department of Obstetrics/Gynecology, University of Nigeria Teaching Hospital, Itukku-Ozalla, Enugu, Nigeria Department of Obstetrics/Gynecology, Enugu State University of Science and Technology Teaching Hospital, Parklane, Enugu, Nigeria
a r t i c l e
i n f o
Article history: Received 15 March 2011 Received in revised form 22 May 2011 Accepted 26 July 2011 Keywords: Nigeria Stillbirth Tertiary health institution
a b s t r a c t Objectives: To determine the stillbirth rate and factors predisposing to a stillbirth delivery at a teaching hospital in Nigeria, with the aim of identifying solutions. Method: A descriptive study of all stillbirths delivered at Enugu State University of Science and Technology Teaching Hospital, Parklane, Nigeria between January 1 and December 31, 2009. The sociodemographic characteristics of the mothers were documented and the possible causes of death were analyzed. Results: There were 153 stillbirths and 2064 total deliveries, giving a stillbirth rate of 74 per 1000 deliveries. Of the stillbirths, 52.3% were fresh and 47.7% were macerated. Women who had not received prenatal care had a significantly higher stillbirth rate (P b 0.05). The most likely cause of a macerated stillbirth was a hypertensive disorder of pregnancy, whereas the likely causes of fresh stillbirths were labor-related. The “3 levels of delay” and injudicious use of oxytocin in labor contributed to the intrapartum stillbirths (P b 0.05). Conclusion: The stillbirth rate recorded in the study institution is unacceptably high. Appropriate prenatal care, timely intervention, and prompt and appropriate intrapartum care are key to achieving a reduction in the stillbirth rate. © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction It is estimated that over 3.2 million stillbirths occur worldwide each year, with the incidence rate being highest in Sub-Saharan Africa. The majority (98%) of stillbirths occur in low- and middle-income countries [1,2]. The estimated annual number of stillbirths globally (3.2 million) is close to the total number of neonatal deaths (3.8 million) [3], and approximates the total number of childhood deaths between the ages of 1 and 5 years [1]. Globally, approximately 1 million intrapartum stillbirths occur and this number exceeds that of child deaths attributable to malaria (820 000) [4]; as such, it deserves commensurate attention and investment. Stillbirth, like any child death, is a source of grief and sorrow to the affected family and may lead to long-term psychological problems [5,6]. Just like the maternal mortality rate, the stillbirth rate has been used as an indicator of the quality of obstetric care, with a high stillbirth rate usually seen in areas with a high maternal mortality rate and a low stillbirth rate in countries with low maternal mortality rates [7]. Stillbirths occurring prenatally (fetal death before the onset of labor) account for two-thirds to three-quarters of all stillbirths globally, whereas the remaining stillbirths are largely associated with complications of labor and/or inadequate care during labor and delivery [7]. The reverse is the case in low-income countries, where a significant proportion of ⁎ Corresponding author at: Department of Obstetrics/Gynecology, University of Nigeria Teaching Hospital, PMB 01129, Itukku-Ozalla, Enugu 234, Nigeria. Tel.: + 234 80 37020 295; fax: + 234 042 252665. E-mail address: [email protected] (E.C. Ezugwu).
stillbirths occur intrapartum resulting in fresh stillbirths. This is a reflection of poor access to and/or poor quality of intrapartum care. The quality of care during the prenatal period directly affects the incidence of prenatal (macerated) stillbirths [8]. Risk factors present during the prenatal period should be identified and properly managed. The perinatal mortality rate is globally accepted as an indicator of the quality of obstetric and neonatal care. With 39 stillbirths and neonatal deaths (occurring in the first week of life) per 1000 pregnancies [9], the perinatal mortality rate in Nigeria is unacceptably high, as it is in many low-income countries. Stillbirths account for approximately 62% of perinatal deaths in West Africa [10], and approximately 60% of stillbirths are intrapartum-related [11] and largely preventable. The majority of infants that survive a severe intrapartum insult and are born alive die shortly afterwards. Some 78%–90% of intrapartum-related neonatal deaths occur within the first 48 hours of birth and nearly all occur within the first week of life [12]. The present study aimed to determine the incidence rate of stillbirths at Enugu State University of Science and Technology Teaching Hospital (ESUTTH), Parklane, Nigeria, and to identify the likely causes and events that may have contributed to the stillbirths with a view to suggesting interventions that will lead to their reduction. The focus is on preventing intrapartum-related stillbirths and neonatal deaths in low-resource countries. This is the first such study on this subject conducted at ESUTTH. 2. Materials and methods The present study is a descriptive study of all stillbirths delivered at ESUTTH between January 1 and December 31, 2009. The teaching
0020-7292/$ – see front matter © 2011 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijgo.2011.05.028
E.C. Ezugwu et al. / International Journal of Gynecology and Obstetrics 115 (2011) 164–166
hospital is a tertiary health facility and a referral center. It is located in Enugu, the capital of Enugu State in southeastern Nigeria. The hospital serves an estimated 6 million people from Enugu State and the neighboring states. It was a general hospital until November 2003, when it was upgraded to become a specialist hospital, and in June 2006 it was again upgraded to become a teaching hospital. The data for the present study were collected prospectively, with cases of fetal death reviewed on a daily basis as they occurred. For every case of stillbirth included in the study, 2 successive women with normal live births were recruited into a comparison group. To enable international comparison, a stillbirth was defined according to the WHO International Classification of Diseases (ICD10) [13] as an infant born after 28 completed weeks of gestation with no heartbeat, even after resuscitation, and a birth weight of 1000 g or more. Intrapartum stillbirths are generally normal in appearance at delivery, with no sign of skin disintegration, and are often called fresh stillbirths. When the skin is not intact, it is referred to as macerated, implying that death occurred more than 12 hours before delivery [21]. Using a prepared pro forma, the sociodemographic characteristics of the mothers were recorded. All mothers who had an intrapartum stillbirth were also interviewed. The relevant condition at death (ReCoDe) classification system [14] was used to identify the most likely causes of macerated stillbirths, and all cases of intrapartum stillbirth were critically reviewed to determine any associated events. The results were analyzed using the statistical software Epi Info version 3.3.2 (Centers for Disease Control and Prevention, Atlanta, GA, USA). P b 0.05 was considered statistically significant. No autopsies could be performed because the parents declined consent, despite appropriate counseling. The study was approved by the Ethics Committee of the study hospital.
3. Results During the 12-month study period, there were 2064 deliveries; 153 of these were stillbirths, giving a stillbirth rate of 74 per 1000 deliveries. Eighty (52.3%) stillbirths were fresh (intrapartum) stillbirths and 73 (47.7%) were macerated stillbirths. The intrapartum stillbirth rate was 39 per 1000 births. Of the intrapartum stillbirths, 43 (53.2%) occurred prior to presentation at the hospital as evidenced by an absence of the fetal heartbeat at presentation. Women who had not received prenatal care had a significantly higher stillbirth risk (odds ratio 1.56; P = 0.04). Age and parity of the mothers with stillbirths did not differ significantly from those with live births (Table 1). The most common likely cause of fetal death in the macerated stillbirth group was hypertensive disease in pregnancy (Table 2). Events that were significantly more common in the intrapartum stillbirth group included 3 levels of delay in obtaining obstetric care, injudicious use of oxytocin in labor, and inadequate intrapartum monitoring (Table 3). Of the 20 women referred to the hospital with a history of an intrapartum bolus injection of oxytocin, 15 (83.3%) experienced uterine rupture and fetal death.
Table 1 Age and parity at delivery.a Characteristic Age, y ≤19 20–39 ≥40 Parity 0 1–4 ≥5 a
Stillbirth group (n = 153)
Control group (n = 306)
P value
15 (9.8) 129 (84.3) 9 (5.9)
22 (7.2) 275 (89.9) 9 (2.9)
0.36 0.09 0.13
31 (20.3) 95 (62.1) 27 (17.6)
76 (24.8) 185 (60.5) 50 (16.3)
0.29 0.54 0.74
Values are given as number (percentage) unless otherwise indicated.
165
Table 2 Causes of macerated stillbirth according to the relevant condition at death (ReCoDe) classification system.a,b Classification
Occurrence in the macerated stillbirth group (n = 97)
Conditions affecting the mother Hypertensive disorders of pregnancy Diabetes mellitus Repeated intake of traditional medicines Severe anemia (hemoglobin b 6 g/dL) Febrile condition preceding stillbirth HIV/AIDS No relevant condition identified Conditions affecting the fetus Congenital anomaly (anencephaly) a b
30 (30.9) 3 (3.1) 8 (8.2) 15 (15.5) 27 (27.8) 4 (4.1) 8 (8.2) 2 (2.1)
Values are given as number (percentage). In some instances, there was more than 1 likely cause of death.
4. Discussion The overall stillbirth rate of 74 per 1000 births recorded in the present institution is unacceptably high. It is twice the estimated value of 32 per 1000 births reported for Sub-Saharan Africa and South Asia, and almost 15 times higher than the rate of 5 stillbirths per 1000 births in high-income countries [1]. The present rate is slightly lower than the rate of 89 stillbirths per 1000 births reported previously for Enugu [15]. Comparably high stillbirth rates have also been reported for other parts of Nigeria, specifically for Ogun (88 stillbirths per 1000 births) [16] and for Lagos (127 stillbirths per 1000 births [adjusted rate]) [17]. Furthermore, a significant proportion of stillbirths remain unrecorded. In Nigeria, nearly two-thirds (62%) of all deliveries occur at home [9] and pregnancies resulting in stillbirth among this group are usually not captured. The actual stillbirth rate in Nigeria, as in other low-income countries, may therefore be even greater than the reported rate because reported rates are usually derived from hospital data. This supports the need for a community-based study. The wide gap between the stillbirth rates in high-income countries and those in economically deprived countries is a reflection of the disparity in access to health care and healthcare quality between the two settings. Such a disparity may also occur within countries [6]. The nearly 10-fold reduction in the rate of stillbirths in highincome countries over the last 40–50 years—from 50 per 1000 births to less than 5 per 1000 births—has been heralded as one of the success stories of modern obstetrics in those countries [18]. This reduction is certainly related to the almost universal availability of, and accessibility to, prenatal and intrapartum care services that focus on prompt risk identification and reduction [1]. In the present study, the majority of stillbirths occurred among women who had not received prenatal care. Prenatal care is a key factor in reducing the stillbirth rate [19,20]. Many of the causes of prenatal stillbirth are potentially preventable, treatable, or modifiable Table 3 Factors potentially contributing to the occurrence of an intrapartum stillbirth.a,b Events
Intrapartum stillbirth group (n = 80)
Control group (n = 160)
P value
Delay in seeking care Delay in transfer from the referral center Delay in receiving care at the hospital d Bolus injection of oxytocin at the referral center Inadequate intrapartum monitoring Wrong diagnosis
36 10 15 18
(45.0%) (12.5%) (18.8%) (22.5%)
6 (3.8%) 3 (1.9%) 4 (2.5%) 2 (1.3%)
0.001 0.0012 0.0001 0.0001
8 (10.0%) 4 (5.0%)
3 (1.9%) 0 (0.0%)
0.0075 0.0117
a b c d
Values are given as number (percentage) unless otherwise indicated. Some cases had more than 1 contributing event. Fisher exact test. Decision–intervention interval at least 1 hour.
c
166
E.C. Ezugwu et al. / International Journal of Gynecology and Obstetrics 115 (2011) 164–166
[21]. Common causes of prenatal stillbirth in the present study were hypertensive disorders of pregnancy, febrile conditions, and severe anemia in pregnancy. With good prenatal care, the majority of these deaths could have been prevented. In a recent demographic and health survey in Nigeria, 36% of the women had not received any prenatal care [9]. Efforts should be geared toward providing universal access to prenatal care. The intrapartum stillbirth rate in the present study was 39/1000 births, with intrapartum stillbirths constituting 52.3% of the overall stillbirth rate. This figure is 5 times higher than the 10% rate expected for settings with optimal intrapartum care [2]. Such a high rate is unacceptable and a clear indication of suboptimal intrapartum care and/or poor access to care. A recent report from a sister institution in Enugu also described a high intrapartum stillbirth rate (52.1 per 1000 births) [15]. The rate of intrapartum stillbirths is highest in West Africa and in South Asian countries with challenging geographic barriers and low access to skilled care [22]. A significant proportion of the women who had a stillbirth did not have access to quality care because of cost barriers. Financial incapacity is one of the main reasons why women in low-income countries do not access care at a health facility even when they are aware of the benefits [23]. Some of these women resort to prayer houses, traditional birth attendants, or unregistered nursing homes staffed by unskilled birth attendants. Seriously unwell women who may have been badly managed at one of these centers are advised to go to a hospital. The present study identified several events that contributed significantly to the occurrence of intrapartum stillbirth. The 3 levels of delay observed in the present study are the same delays that have previously been shown to be major contributors to maternal mortality in Sub-Saharan Africa [24]. They include delays in seeking appropriate care (level-1 delay) because of financial challenges, and delays in transporting women with emergency obstetric complications to the hospital (level-2 delay). Although the present government is making efforts to bring health facilities with emergency obstetric care closer to the people, the pace is worrisome. Many women face substantial barriers to access emergency obstetric care because of the poor transportation infrastructure (bad roads) and challenging security issues. Another significant contributory event to intrapartum stillbirth observed in the present study was the injudicious administration of bolus oxytocin to expedite labor at maternity homes and prayer houses. This calls for training and retraining of nurses and midwifes in maternity homes and supports a call for closure of all unregistered delivery facilities. All maternity homes must be supervised and properly regulated by regulatory agencies constituted by the government. Institutional delays (level-3 delays, evidenced by the prolonged decision–intervention interval) also contributed significantly to the occurrence of intrapartum stillbirths, as has been reported previously [25,26], and this must be addressed. These delays consisted mainly of time spent waiting for the anesthetist and senior obstetrician to arrive for the emergency cesarean delivery and delays in the process of securing blood and other items that are required for emergency operations. Although the hospital is expected to provide all items necessary for an emergency cesarean delivery, the “out-of-stock syndrome” in the present hospital, as in many hospitals in low-income countries, is a big challenge. If an item is unavailable at the hospital, it is up to the patient's relatives to procure it, often at odd hours. The need to reduce the rate of intrapartum stillbirths calls for adequate intrapartum monitoring, and prompt and timely intervention in obstetric emergencies. To achieve this, a multifaceted approach is required that will remove all barriers to access to emergency obstetric care, implement a system of prompt and early referral, and improve transportation. The concepts of birth readiness and emergency preparedness should be encouraged. Stillbirth is a global problem that is admittedly worse in lowincome countries. Its reduction deserves as much attention as the reductions of neonatal mortality and under-5 mortality, which are
both Millennium Development Goal indicators. Therefore, we recommend a holistic and multidisciplinary approach that will empower women economically to eliminate the cost barrier to access to care, that will take health facilities closer to the people, and that will encourage an efficient and effective referral system. The aim should be to achieve optimal intrapartum monitoring as well as appropriate and timely intervention when required. There should be regular workshops, and training and retraining of service providers at all levels. Emergency drills may help define and test protocols for the management of obstetric emergencies. Conflict of interest The authors have no conflicts of interest. References [1] Stanton C, Lawn JE, Rahman H, Wilczynska-Ketende K, Hill K. Stillbirth rates: delivering estimates in 190 countries. Lancet 2006;367(9521):1487–94. [2] WHO. Neonatal and Perinatal Mortality. www.who.int. http://www.who.int/ making_pregnancy_safer/publications/neonatal.pdf. 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