Preventable stillbirths in India and Pakistan: a prospective, observational study

Abstract

Objective Stillbirths occur 10–20 times more frequently in low‐income settings compared with high‐income settings. We created a methodology to define the proportion of stillbirths that are potentially preventable in low‐income settings and applied it to stillbirths in sites in India and Pakistan. Design Prospective observational study. Setting Three maternity hospitals in Davangere, India and a large public hospital in Karachi, Pakistan. Population All cases of stillbirth at ≥20 weeks of gestation occurring from July 2018 to February 2020 were screened for participation; 872 stillbirths were included in this analysis. Methods We prospectively defined the conditions and gestational ages that defined the stillbirth cases considered potentially preventable. Informed consent was sought from the parent(s) once the stillbirth was identified, either before or soon after delivery. All information available, including obstetric and medical history, clinical course, fetal heart sounds on admission, the presence of maceration as well as examination of the stillbirth after delivery, histology, and polymerase chain reaction for infectious pathogens of the placenta and various fetal tissues, was used to assess whether a stillbirth was potentially preventable. Main outcome measures Whether a stillbirth was determined to be potentially preventable and the criteria for assignment to those categories. Results Of 984 enrolled, 872 stillbirths at ≥20 weeks of gestation met the inclusion criteria and were included; of these, 55.5% were deemed to be potentially preventable. Of the 649 stillbirths at ≥28 weeks of gestation and ≥1000 g birthweight, 73.5% were considered potentially preventable. The most common conditions associated with a potentially preventable stillbirth at ≥28 weeks of gestation and ≥1000 g birthweight were small for gestational age (SGA) (52.8%), maternal hypertension (50.2%), antepartum haemorrhage (31.4%) and death that occurred after hospital admission (15.7%). Conclusions Most stillbirths in these sites were deemed preventable and were often associated with maternal hypertension, antepartum haemorrhage, SGA and intrapartum demise. Tweetable abstract Most stillbirths are preventable by better care for women with hypertension, growth restriction and antepartum haemorrhage.

Authors' response: Are these stillbirths really preventable? Re: Preventable stillbirths in India and Pakistan: a prospective, observational study

“…We agree that small for gestational age, maternal hypertension and antepartum hemorrhage are the common conditions associated with potentially preventable stillbirths. 1,4 However, death after hospital admission does not represent preventability in the true sense in resourceconstrained settings, such as ours, that have high patient burden. This is commonly seen in our set-up, where parents refuse cesarean deliveries for fetal indications when there is no space in the neonatal intensive care unit.…”

“…We thank Drs Sharma and Aggarwal for their positive comments about our PURPOSe study. 1 We are pleased to acknowledge their efforts and those of others to determine which stillbirths might be preventable.…”

“…We congratulate Goldenberg et al 1 on their prospective work on stillbirth in two countries: one with the highest number of stillbirths and the other with the highest stillbirth rate. We have been working with World Health Organization (WHO) South-East Asia Region to establish facility-based stillbirth surveillance in South-East Asia since 2011.…”

“…We are grateful to Drs Braillon and Bewley for their interest in our recent paper in BJOG 1 and would like to elaborate on some of the important points they raise.…”

Preventability of stillbirths: context matters

“…Rather than analysing the fetal and maternal condition individually, the maternal-fetal dyad should be assessed as recommended by the WHO International Classification of Disease-Perinatal Mortality system of classification. 2,3 Similarly, maternal conditions like anaemia, medical disorders and maternal infections (malaria, syphilis and vaccine-preventable infections) need to be correlated with the fetus, and whether the fetus has sequelae of congenital infection or fetal growth disorder.…”