IJG-08334; No of Pages 5 International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
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International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
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Risk factors for stillbirths in Tete, Mozambique
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Diederike Geelhoed a,⁎, Jocelijn Stokx b, Xavier Mariano c, Carla Mosse Lázaro d, Kristien Roelens e
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Article history: Received 6 September 2014 Received in revised form 22 February 2015 Accepted 24 April 2015
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Keywords: Emergency obstetric care Mozambique Risk factors Stillbirths
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International Centre for Reproductive Health-Mozambique, Maputo, Mozambique Institute for Tropical Medicine, Antwerp, Belgium c Faculty of Health Science, Zambeze University, Tete, Mozambique d Tete Provincial Health Directorate-Mozambique, Tete, Mozambique e Department of Obstetrics and Gynecology, Ghent University Hospital, Ghent, Belgium
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Objective: To evaluate known risk factors for stillbirth and identify local priorities for stillbirth prevention among institutional deliveries in Tete, Mozambique. Methods: A case–control study was conducted among 150 women who experienced stillbirths and 300 women who experienced live deliveries at three health facilities between December 1, 2009, and April 30, 2011. Case and control individuals were matched for health facility, age, and parity. Sociodemographic, pregnancy, and delivery characteristics (including HIV and syphilis serology) were assessed. Bivariate associations and a conditional logistic regression model identified variables contributing to fetal outcome. Results: No between-group differences were recorded in the frequency of infection with HIV (25 [16.7%] cases vs 55 [18.3%] controls; P = 0.663) or syphilis (6 [4.0%] vs 16 [5.3%]; P = 0.536) at delivery. Multivariate analysis revealed that stillbirth was associated with direct obstetric complications (mutually adjusted odds ratio [OR] 6.7; 95% confidence interval [CI] 3.6–12.1), low socioeconomic status (mutually adjusted OR 1.8; 95% CI 1.1–3.1), and referral during childbirth (mutually adjusted OR 3.2; 95% CI 1.7–6.1). Conclusion: Stillbirths in Tete, Mozambique, were predominantly caused by direct obstetric complications requiring referral among women of low socioeconomic status. Prenatal management of HIV and syphilis limited effects on fetal outcome. Emergency obstetric care and referral systems should be the focus of interventions aimed at stillbirth prevention. © 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
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1. Introduction
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High perinatal mortality remains a problem for many low-income countries, including Mozambique. According to WHO, approximately half of all perinatal mortality reflects intrauterine fetal death during pregnancy and childbirth [1]. Many stillbirths are associated with obstetric complications or maternal infectious diseases, including syphilis and possibly HIV [2–4]. Southern Africa has a heavy burden of such diseases, and stillbirths attributed to infections are reported to occur frequently [5,6]. Consequently, screening and management of syphilis and HIV during pregnancy has been widely introduced in the past decade [7,8]. Despite these efforts, little progress has been made in reducing perinatal mortality (including stillbirths) in Sub-Saharan Africa; indeed,
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⁎ Corresponding author at: International Centre for Reproductive Health-Mozambique, Av. Maguiguana, Praceta 1067, Rua Projectada, Prédio no. 100, 2o Andar, Maputo, Mozambique. Tel.: +258 21 320507, +258 82 3077814, +258 82 0731927; fax: +258 21 320507. E-mail addresses: [email protected], [email protected], [email protected] (D. Geelhoed).
many countries in this region report a stillbirth rate of greater than 25 per 1000 births [9]. The stillbirth rate in Mozambique is even higher, at 29 per 1000 births in 2008, and shows little sign of falling [10]. Furthermore, routine reports from local health authorities have highlighted a persistently high institutional stillbirth rate of 43 per 1000 births for Tete City, a town in northwestern Mozambique with approximately 175 000 inhabitants [11]. Tete has acceptable coverage of free obstetric services (including basic and complete emergency obstetric care) and prenatal care, with HIV and syphilis screening and management. Use of services is high because almost all pregnant women in the local population complete at least one prenatal care visit, and many give birth in the city’s maternity wards. However, the local health system presents challenges for quality of care, including lack of adequately qualified staff, functional equipment, and ambulances for emergency referrals, as well as an irregular supply of essential drugs. The prevalence of syphilis and HIV among pregnant women in Tete is estimated to be 5% [12] and 19% [13], respectively. The aim of the present study was to evaluate the relative importance of known risk factors for institutional stillbirth in Tete so that future priorities for stillbirth prevention could be identified.
http://dx.doi.org/10.1016/j.ijgo.2015.03.027 0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Geelhoed D, et al, Risk factors for stillbirths in Tete, Mozambique, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/ j.ijgo.2015.03.027
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A total of 169 potential cases were identified during the present study period, but 19 (11.2%) were excluded owing to incomplete data collection. Likewise, 359 potential controls were identified but 59 (16.4%) were excluded for not completing the data collection process. Consequently, the case and control groups included 150 and 300 women, respectively. Of the 150 cases, 50 (33.3%) had a fetal heartbeat on arrival in the health facility of first contact, 70 (46.7%) no fetal heartbeat on arrival, and 30 (20.0%) no information regarding fetal heartbeat on arrival, indicating that between 33.3% and 53.3% (including cases for which no information was available) of stillbirths occurred during labor or childbirth after arrival in a health facility. No significant differences between groups were detected for sociodemographic characteristics (Table 1). The distributions of various known risk factors for stillbirth are presented in Table 2. The frequencies of positive HIV or syphilis test results at childbirth were not significantly different between the two groups. Among all 450 women, 80 (17.8%) tested positive for HIV at childbirth, 58 (72.5%) of whom were known to be HIV positive during or before
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3. Results
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A case–control study was conducted in three maternity facilities in Tete between December 1, 2009, and April 30, 2011. Women included in the case group were mothers of neonates born without signs of life after at least 28 weeks of pregnancy and/or with a birth weight of at least 1500 g, according to what is usually considered as stillbirth in Mozambique. Women included in the control group had had live births; they were matched to cases on the basis of health facility attended and the strata of maternal age and parity. The present study conformed to the internationally recognized ethical standards for health research and was authorized by both national and local health authorities in Mozambique. Approval was obtained from the Mozambican Ministry of Health and Ghent University Hospital, Belgium. All participants provided written informed consent. The sites selected for the present study included two urban health centers (No 2 and No 4) designated to give basic emergency obstetric care. Both these health centers provide one nurse specializing in maternal and child health per shift in the maternity ward. The third site was Tete Provincial Hospital, which offers comprehensive emergency obstetric care. On a per shift basis, this hospital provides two specialist nurses in the maternity ward, one non-specialist clinician, one specialist clinician (gynecologist or surgeon) on-call, and one surgical team [14]. All three facilities regularly have insufficient stock of essential medications for emergency obstetric care. Deliveries at these centers account for more than 90% of all institutional births in Tete each year (approximately 8000 births in total); the remaining births take place in small health facilities. Tete Provincial Hospital is accessible to patients either directly or through referral from health centers within or outside the city. Recruitment and data collection were performed by four trained research assistants shortly after delivery at all three study sites. Controls were selected in parallel to cases: the first subsequent woman with correct matching criteria was invited to enroll in the control group. Every eligible participant received a personal identification number for use in data collection. A structured face-to-face interview (in the local language) and a review of the medical files (in Portuguese) were conducted to assess prenatal and delivery care. A venous blood sample was taken for laboratory analysis at Tete Provincial Hospital. All instruments were pretested and the principal investigators closely supervised ongoing data collection and laboratory procedures. The interview provided information not routinely recorded in the medical file, including level of education, occupation of the participant and her partner, availability of water and electricity at the participant’s home (subsequently combined into the variable socioeconomic status), smoking, alcohol consumption, height, and weight. The medical files provided all other pertinent information, including medical history and care during pregnancy and childbirth, HIV and syphilis serology, and newborn characteristics. Fetal heartbeat on arrival was determined by auscultation with a Pinard fetoscope on arrival at the health facility of first contact (either one of three study sites or another facility with subsequent referral to a study site). However, a negative fetal heartbeat on arrival at the health facility of first contact did not necessarily reflect prepartum intrauterine death. Many women started labor at home but faced considerable delays before reaching a health facility owing to late recognition of complications while at home, slow decision making to seek professional assistance (which often involved key male relatives), and difficulties in obtaining transport to attend the nearest health facility. Variables related to complications and progress of labor and delivery reflected only events observed within the health system, because medical files did not usually record any events that occurred before admission. Laboratory tests were performed following standardized procedures. Infection with HIV was diagnosed by detection of antibodies using either the Determine HIV-1/2 test (Abbott Laboratories, Chicago, IL, USA) or the Uni-Gold Recombigen HIV-1/2 test (Trinity Biotech, Bray, Ireland). Syphilis was diagnosed by antibody testing and titration using either the Macro-Vue rapid plasma reagin (RPR) card test (BD
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Diagnostics, Sparks, MD, USA) or the SERODIA Treponema pallidum particle agglutination (TPPA) test (Fujirebio Diagnostics, Malvern, PA, USA). Syphilis and HIV tests performed at childbirth complemented the results of tests performed during prenatal care (often at the first visit), because they permitted the identification of seroconversion during pregnancy after starting prenatal care and the titration of syphilis antibodies. Participants were encouraged to collect test results from maternity staff using their personal identification number; any treatment required was administered in accordance with national standards. Quality control of in-house laboratory testing was performed in the national reference laboratory at Maputo for all positive test results and 15% of all negative test results. The required sample size was calculated as 150 cases plus 300 controls, with a confidence interval of 95% and power of at least 80%. These values were based on the reported prevalence of syphilis and HIV in Tete [12,13], with the expectation of at least four-fold (syphilis) and two-fold (HIV) increased seropositivity among the cases than the controls [15–17]. Recruitment continued until the required number of participants for whom all necessary data collection steps (informed consent, interview, medical file review, and laboratory results) had been completed was reached. The number of participants who had completed all the necessary data collection steps was verified; only those with all four steps completed were included in the present analysis. All data were digitized using EPI Info version 3.5.1 (Centers for Disease Control and Prevention, Atlanta, GA, USA). Observations were then validated by double data entry and analyzed using Stata/IC version 11.2 (Stata Corp, College Station, TX, USA). Differences in proportions were calculated using χ2 tests; P b 0.05 was considered statistically significant. Many of the variables examined in the present study were interdependent; therefore, a multivariate analysis was conducted to determine which of the possible explanatory factors influenced the outcome of stillbirth. A conditional logistic regression model was fitted by stepwise elimination of variables that did not contribute significantly to fit (initially taken as P b 0.10, followed by P b 0.05). Sociodemographic factors considered in this model were parity, socioeconomic status (low vs other), residence (in Tete vs outside Tete), and total number of prenatal visits (≥4 vs b4). Obstetric factors were direct complications during pregnancy and childbirth (prolonged labor, ruptured uterus, hemorrhage, preeclampsia, sepsis, and cord complications), indirect complications during pregnancy and childbirth (malaria, anemia, and non-obstetric sepsis), referral during pregnancy and childbirth, instrumental or operative delivery, and level of the attending health professional (medical doctor/ specialist vs other). Additional factors considered were body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters; b18.5 vs ≥18.5) and alcohol use.
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Please cite this article as: Geelhoed D, et al, Risk factors for stillbirths in Tete, Mozambique, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/ j.ijgo.2015.03.027
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D. Geelhoed et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx Table 1 Characteristics of the study population.a
Age, y Mean (95% confidence interval) Median (range) b20 b ≥35 b Parity 0 1–3 ≥4 Married or in a stable relationship Maternity facility attended Tete Provincial Hospital Health center no 2 Health center no 4
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24.7 (23.4–26.2)
P value
24.1 (23.3–24.8)
24 (15–39) 45/149 (30.2) 11/149 (7.4)
24 (15–39) 94/297 (31.6) 21/297 (7.1)
51 (34.0) 47 (31.3) 52 (34.7) 140 (93.3)
102 (34.0) 96 (32.0) 102 (34.0) 287 (95.7)
0.755 0.904 0.992
0.289 N0.99
114 (76.0) 25 (16.7) 11 (7.3)
228 (76.0) 50 (16.7) 22 (7.3)
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Table 2 Factors assumed to be associated with stillbirth.a
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t2:3
Factor
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Low educational level b Low socioeconomic level c Residence in Tete Regular prenatal care d BMI Range Mean (95% confidence interval) b18.5 ≥30 Smoking during pregnancy Alcohol consumption Positive HIV test result at delivery Positive TPPA syphilis test result at delivery Treatment for acute malaria during pregnancy
t2:21 t2:22 t2:23 t2:24 t2:25 t2:26 t2:27 t2:28
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pregnancy. Antiretroviral medication for the treatment or prevention of mother-to-child transmission of HIV was administered to 45 (56.3%) women; the remaining 35 (43.7%) women either did not, or probably did not, receive such intervention. Analysis of syphilis testing performed during pregnancy using an unspecified syphilis test suggested that 15 (3.3%) of the 450 women had positive results at this stage. However, syphilis testing at childbirth using either the RPR test or the TPPA test indicated that between 22 (4.9%; RPR) and 27 (6.0%; TPPA) of the women had positive results. Titration of blood samples giving positive RPR or TPPA test results resulted in low titers, suggesting that active syphilis infection was uncommon among the present study cohort. One (2.4%) woman in the control group who tested positive for syphilis at childbirth using both the RPR and the TPPA tests had failed to receive benzathine penicillin on at least one occasion during pregnancy. The highest possible prevalence of syphilis was estimated as 9.3% given the number of women with at least one positive test result at any time during pregnancy or childbirth (i.e. 42 of 450).
Control group (n = 300)
P value
81 (54.0) 77/129 (59.7) 87/150 (58.0) 3/150 (2.0)
126 (42.0) 96/262 (36.6) 258/294 (87.8) 23/266 (8.6)
0.021 b0.001 b0.001 0.007
16.1–39.1 23.0 (22.4–23.5)
15.5–42.5 23.7 (23.1–24.2)
13/149 (8.7) 5/149 (3.4) 0 (0.0) 4 (2.7) 25 (16.7) 6 (4.0)
21/299 (7.0) 33/299 (11.0) 3 (1.0) 27 (9.0) 55 (18.3) 16 (5.3)
0.522 0.006 0.219 0.012 0.663 0.536
4/146 (2.7)
6/268 (2.2)
0.751
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Stillbirth group (n = 150)
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by the square of height in meters); TPPA, Treponema pallidum particle agglutination. a Values given as number (percentage) or number/number for whom data were available, unless indicated otherwise. b No formal education or incomplete primary school education. c No formal education or incomplete primary school education, non-skilled occupations of participant and her partner, and neither water nor electricity connections at home. d Four or more visits distributed over all three trimesters, as recommended in national guidelines.
4. Discussion
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The present study provided evidence that the high institutional stillbirth rate recorded in the Mozambican town of Tete City [11] largely reflects direct obstetric complications, particularly among women of low socioeconomic status and those who commence skilled care during childbirth in a peripheral health facility with subsequent referral. Overall, 33.3%–53.3% of stillbirths in the present study period occurred during labor or delivery after arrival at the health facility of first contact, during transfer, or at the referral hospital. Such outcomes might be prevented through improved provision of emergency obstetric care [18]. The observed pattern of emergency obstetric care suggested a paradox in the health system in Tete City. In many cases, cesareans were conducted to deliver neonates already dead on arrival—although some of these procedures might have been unavoidable owing to severe maternal complications, such as ruptured uterus. By contrast, few cesareans were performed to deliver live neonates. This finding suggested the need for cesarean delivery has been poorly defined, as has been reported previously in Tanzanian hospitals [19]. Neither syphilis nor HIV was significantly associated with an outcome of stillbirth in the present study, despite considerable prevalence and the introduction of screening and treatment in prenatal care in 2002. It appears that these infections were diagnosed and treated sufficiently to avoid its sequels in the fetus. In the case of prenatal syphilis diagnosis and treatment, the benefits for fetal survival have been well documented, but the benefits of HIV diagnosis and treatment are less certain [20,21]. Nevertheless, diagnosis and management of HIV were still far from satisfactory considering mother and child health in general. Only 72.5% of all women with HIV were diagnosed during or before pregnancy and just 56.3% received any antiretroviral medication. Further improvements in HIV testing during pregnancy and childbirth are obviously required, as are improvements in the provision of medication for maternal health and prevention of mother-to-child transmission. As reported elsewhere [2,6], the known limitations of the local health system were likely to be the underlying cause for the prevalence of fetal death in Tete. Data on availability of staff, equipment, medication, cars for emergency referrals, and other features of the health system were not collected in the present study. However, improvements in the quality of emergency obstetric care services are obviously required to address the high stillbirth rate in Tete [14,22,23]. Many interventions that could feasibly be implemented in this setting have proven efficacious for achieving such improvements [24–28]. These interventions include correct and consistent use of the partogram—a graphic record of progress of labor against time elapsed, detailing cervical dilatation, descent of the presenting part, frequency and strength of contractions, and vital signs of mother and fetus—for the timely
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Values given as number (percentage) unless indicated otherwise. Values are given as number/number for whom data are available (percentage).
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Control group (n = 300)
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Direct obstetric complications at childbirth, emergency obstetric care, and mode of delivery were significantly different between the two groups (Table 3). Direct obstetric complications—prolonged labor, ruptured uterus, prepartum hemorrhage, and obstetric sepsis—occurred more frequently in the stillbirth group than the control group (P b 0.001 for all). Cord complications were also more frequent in the stillbirth group than the control group (P b 0.001). Probably as a consequence of these complications, more women in the stillbirth group had been referred from a peripheral health facility to Tete Provincial Hospital during childbirth (P b 0.001). Significantly more women in this group than in the control group underwent cesarean delivery, hysterectomy, blood transfusion, and treatment with antibiotics (P b 0.001 for all). Vacuum extraction and intravenous oxytocin were rarely used in either group. After stepwise removal of variables least contributing to fit, direct obstetric complications (mutually adjusted odds ratio [OR] 6.7; 95% confidence interval [CI] 3.6–12.1), referral during childbirth (mutually adjusted OR 3.2; 95% CI 1.7–6.1), and low socioeconomic level (mutually adjusted OR 1.8; 95% CI 1.1–3.1) were all found to contribute to the observed variability in between-group fetal outcomes.
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t1:1 t1:2
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Please cite this article as: Geelhoed D, et al, Risk factors for stillbirths in Tete, Mozambique, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/ j.ijgo.2015.03.027
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Table 3 Characteristics of obstetric complications and care.a Characteristic
Stillbirth group (n = 150)
Control group (n = 300)
P value
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Direct obstetric complications Prolonged labor b Ruptured uterus (as recorded in the medical file) Prepartum hemorrhage (as recorded in the medical file) Pre-eclampsia and/or eclampsia c Sepsis owing to obstetric causes, including chorioamnionitis (as recorded in the medical file) Cord complications, including prolapse (as recorded in the medical file) Malpresentation (as recorded in the medical file) Referral from a peripheral health center to Tete Provincial Hospital during labor or delivery Instrumental or operative childbirth Caesarean delivery Hysterectomy Vacuum extraction Oxytocin administered intravenously during labor or delivery Antibiotic treatment Blood transfusion Anticonvulsive treatment Antihypertensive treatment Traditional treatment d
110/147 (74.8) 66 (44.0) 17 (11.3) 21 (14.0) 9/149 (6.0) 12 (8.0) 22 (14.7) 7 (4.7) 62 (41.3) 68 (45.3) 64 (42.7) 9 (6.0) 4/149 (2.7) 3 (2.0) 51 (34.0) 20 (13.3) 6 (4.0) 2 (1.3) 1 (0.7)
83/287 (28.9) 44 (14.7) 0 (0.0) 3 (1.0) 18/288 (6.3) 3/299 (1.0) 1 (0.3) 6 (2.0) 32/297 (10.8) 53 (17.7) 50 (16.7) 0 (0.0) 3 (1.0) 8 (2.7) 40 (13.3) 2 (0.7) 9 (3.0) 3 (1.0) 7 (2.3)
b0.001 b0.001 b0.001 b0.001 0.931 b0.001 b0.001 0.111 b0.001 b0.001 b0.001 b0.001 0.175 0.666 b0.001 b0.001 0.577 0.750 0.207
t3:23 t3:24 t3:25 t3:26
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310
Acknowledgments
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The Flemish International Cooperation Agency funded the present study as part of the Integrated Network for the Fight Against HIV/AIDS/ STI in Tete Province, Mozambique project. Additional financial support was provided by the Program for Inter-University Collaboration of Eduardo Mondlane University, Mozambique, and the Flemish Inter-University Council, which is funded by the Belgium Development Cooperation.
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Conflict of interest
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References
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diagnosis and referral of cases of prolonged labor during the latent and active phases of labor. Improved systems for communication and collaboration between the referring center and referral health facilities is also essential, including provision of a fleet of well maintained vehicles for transport of patients between sites. Consistent adherence to national protocols for emergency obstetric care should be enhanced through the use of regular emergency care drills to improve practical skills of midwives. Supportive supervision of labor wards, investments in personnel and equipment, and improved supply chain management are also indispensable. Constructive audit of maternal and neonatal complications and deaths, introduced in Mozambique since 2010, will aid identification and mitigation of persisting systematic weaknesses. Beyond the lack of data collection on health system failings, the present study was limited in that it only involved women within the health system of Tete. Often, it was impossible to identify whether the stillbirth had occurred prepartum or intrapartum. This distinction is important because prepartum stillbirths tend to be caused by maternal disease or growth retardation, whereas intrapartum stillbirths often reflect obstetric complications. In addition, risk factors for stillbirth might be different between women from Tete, who live close to a health facility and often have a high socioeconomic status, and women living in the surrounding areas. Unfortunately, the sample size was insufficient to perform additional analyses for these subgroups. In conclusion, findings on risk factors for stillbirth in Tete were largely in line with those previously reported. The present study has provided valid evidence to suggest that emergency obstetric care and referral systems should be the focus for future interventions aimed at stillbirth prevention in Mozambique.
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Values given as number (percentage) or number/number for whom data were available, unless indicated otherwise. Active first stage of labor lasting N6 h or second stage of labor lasting N1 h. Diastolic blood pressure ≥90 mm Hg (or an increase of 15 mm Hg) and/or systolic blood pressure ≥140 mm Hg (or an increase of 30 mm Hg), with or without convulsions. Unspecified non-medically prescribed treatment, according to the local cultural traditions.
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The authors have no conflicts of interest.
Please cite this article as: Geelhoed D, et al, Risk factors for stillbirths in Tete, Mozambique, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/ j.ijgo.2015.03.027
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[24] Wagaarachchi PT, Graham WJ, Penney GC, McCaw-Binns A, Yeboah Antwi K, Hall MH. Holding up a mirror: changing obstetric practice through criterion-based clinical audit in developing countries. Int J Gynecol Obstet 2001;74(2):119–31. [25] Chaillet N, Dubé E, Dugas M, Audibert F, Tourigny C, Fraser WD, et al. Evidence-based strategies for implementing guidelines in obstetrics: a systematic review. Obstet Gynecol 2006;108(5):1234–45. [26] Nyamtema AS, de Jong AB, Urassa DP, van Roosmalen J. Using audit to enhance quality of maternity care in resource limited countries: lessons learnt from rural Tanzania. BMC Pregnancy Childbirth 2011;11:94. [27] Johanson R, Akhtar S, Edwards C, Dewan F, Haque Y, Jones P. MOET: Bangladesh–an initial experience. J Obstet Gynaecol Res 2002;28(4):217–23. [28] Raven J, Utz B, Roberts D, van den Broek N. The 'Making it Happen' programme in India and Bangladesh. BJOG 2011;118(Suppl. 2):100–3.
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[19] Maaløe N, Sorensen BL, Onesmo R, Secher NJ, Bygbjerg IC. Prolonged labour as indication for emergency caesarean section: a quality assurance analysis by criterionbased audit at two Tanzanian rural hospitals. BJOG 2012;119(5):605–13. [20] Hawkes S, Matin N, Broutet N, Low N. Effectiveness of interventions to improve screening for syphilis in pregnancy: a systematic review and meta-analysis. Lancet Infect Dis 2011;11(9):684–91. [21] Ishaque S, Yakoob MY, Imdad A, Goldenberg RL, Eisele TP, Bhutta ZA. Effectiveness of interventions to screen and manage infections during pregnancy on reducing stillbirths: a review. BMC Public Health 2011;11(Suppl. 3):S3. [22] Pattinson R, Kerber K, Buchmann E, Friberg IK, Belizan M, Lansky S, et al. Stillbirths: how can health systems deliver for mothers and babies? Lancet 2011;377(9777): 1610–23. [23] Bhutta ZA, Yakoob MY, Lawn JE, Rizvi A, Friberg IK, Weissman E, et al. Stillbirths: what difference can we make and at what cost? Lancet 2011;377(9776):1523–38.
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Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
2Q1
Risk factors for stillbirths in Tete, Mozambique
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Diederike Geelhoed a,⁎, Jocelijn Stokx b, Xavier Mariano c, Carla Mosse Lázaro d, Kristien Roelens e
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Article history: Received 6 September 2014 Received in revised form 22 February 2015 Accepted 24 April 2015
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Keywords: Emergency obstetric care Mozambique Risk factors Stillbirths
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International Centre for Reproductive Health-Mozambique, Maputo, Mozambique Institute for Tropical Medicine, Antwerp, Belgium c Faculty of Health Science, Zambeze University, Tete, Mozambique d Tete Provincial Health Directorate-Mozambique, Tete, Mozambique e Department of Obstetrics and Gynecology, Ghent University Hospital, Ghent, Belgium
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Objective: To evaluate known risk factors for stillbirth and identify local priorities for stillbirth prevention among institutional deliveries in Tete, Mozambique. Methods: A case–control study was conducted among 150 women who experienced stillbirths and 300 women who experienced live deliveries at three health facilities between December 1, 2009, and April 30, 2011. Case and control individuals were matched for health facility, age, and parity. Sociodemographic, pregnancy, and delivery characteristics (including HIV and syphilis serology) were assessed. Bivariate associations and a conditional logistic regression model identified variables contributing to fetal outcome. Results: No between-group differences were recorded in the frequency of infection with HIV (25 [16.7%] cases vs 55 [18.3%] controls; P = 0.663) or syphilis (6 [4.0%] vs 16 [5.3%]; P = 0.536) at delivery. Multivariate analysis revealed that stillbirth was associated with direct obstetric complications (mutually adjusted odds ratio [OR] 6.7; 95% confidence interval [CI] 3.6–12.1), low socioeconomic status (mutually adjusted OR 1.8; 95% CI 1.1–3.1), and referral during childbirth (mutually adjusted OR 3.2; 95% CI 1.7–6.1). Conclusion: Stillbirths in Tete, Mozambique, were predominantly caused by direct obstetric complications requiring referral among women of low socioeconomic status. Prenatal management of HIV and syphilis limited effects on fetal outcome. Emergency obstetric care and referral systems should be the focus of interventions aimed at stillbirth prevention. © 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
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1. Introduction
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High perinatal mortality remains a problem for many low-income countries, including Mozambique. According to WHO, approximately half of all perinatal mortality reflects intrauterine fetal death during pregnancy and childbirth [1]. Many stillbirths are associated with obstetric complications or maternal infectious diseases, including syphilis and possibly HIV [2–4]. Southern Africa has a heavy burden of such diseases, and stillbirths attributed to infections are reported to occur frequently [5,6]. Consequently, screening and management of syphilis and HIV during pregnancy has been widely introduced in the past decade [7,8]. Despite these efforts, little progress has been made in reducing perinatal mortality (including stillbirths) in Sub-Saharan Africa; indeed,
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⁎ Corresponding author at: International Centre for Reproductive Health-Mozambique, Av. Maguiguana, Praceta 1067, Rua Projectada, Prédio no. 100, 2o Andar, Maputo, Mozambique. Tel.: +258 21 320507, +258 82 3077814, +258 82 0731927; fax: +258 21 320507. E-mail addresses: [email protected], [email protected], [email protected] (D. Geelhoed).
many countries in this region report a stillbirth rate of greater than 25 per 1000 births [9]. The stillbirth rate in Mozambique is even higher, at 29 per 1000 births in 2008, and shows little sign of falling [10]. Furthermore, routine reports from local health authorities have highlighted a persistently high institutional stillbirth rate of 43 per 1000 births for Tete City, a town in northwestern Mozambique with approximately 175 000 inhabitants [11]. Tete has acceptable coverage of free obstetric services (including basic and complete emergency obstetric care) and prenatal care, with HIV and syphilis screening and management. Use of services is high because almost all pregnant women in the local population complete at least one prenatal care visit, and many give birth in the city’s maternity wards. However, the local health system presents challenges for quality of care, including lack of adequately qualified staff, functional equipment, and ambulances for emergency referrals, as well as an irregular supply of essential drugs. The prevalence of syphilis and HIV among pregnant women in Tete is estimated to be 5% [12] and 19% [13], respectively. The aim of the present study was to evaluate the relative importance of known risk factors for institutional stillbirth in Tete so that future priorities for stillbirth prevention could be identified.
http://dx.doi.org/10.1016/j.ijgo.2015.03.027 0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
Please cite this article as: Geelhoed D, et al, Risk factors for stillbirths in Tete, Mozambique, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/ j.ijgo.2015.03.027
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A total of 169 potential cases were identified during the present study period, but 19 (11.2%) were excluded owing to incomplete data collection. Likewise, 359 potential controls were identified but 59 (16.4%) were excluded for not completing the data collection process. Consequently, the case and control groups included 150 and 300 women, respectively. Of the 150 cases, 50 (33.3%) had a fetal heartbeat on arrival in the health facility of first contact, 70 (46.7%) no fetal heartbeat on arrival, and 30 (20.0%) no information regarding fetal heartbeat on arrival, indicating that between 33.3% and 53.3% (including cases for which no information was available) of stillbirths occurred during labor or childbirth after arrival in a health facility. No significant differences between groups were detected for sociodemographic characteristics (Table 1). The distributions of various known risk factors for stillbirth are presented in Table 2. The frequencies of positive HIV or syphilis test results at childbirth were not significantly different between the two groups. Among all 450 women, 80 (17.8%) tested positive for HIV at childbirth, 58 (72.5%) of whom were known to be HIV positive during or before
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3. Results
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A case–control study was conducted in three maternity facilities in Tete between December 1, 2009, and April 30, 2011. Women included in the case group were mothers of neonates born without signs of life after at least 28 weeks of pregnancy and/or with a birth weight of at least 1500 g, according to what is usually considered as stillbirth in Mozambique. Women included in the control group had had live births; they were matched to cases on the basis of health facility attended and the strata of maternal age and parity. The present study conformed to the internationally recognized ethical standards for health research and was authorized by both national and local health authorities in Mozambique. Approval was obtained from the Mozambican Ministry of Health and Ghent University Hospital, Belgium. All participants provided written informed consent. The sites selected for the present study included two urban health centers (No 2 and No 4) designated to give basic emergency obstetric care. Both these health centers provide one nurse specializing in maternal and child health per shift in the maternity ward. The third site was Tete Provincial Hospital, which offers comprehensive emergency obstetric care. On a per shift basis, this hospital provides two specialist nurses in the maternity ward, one non-specialist clinician, one specialist clinician (gynecologist or surgeon) on-call, and one surgical team [14]. All three facilities regularly have insufficient stock of essential medications for emergency obstetric care. Deliveries at these centers account for more than 90% of all institutional births in Tete each year (approximately 8000 births in total); the remaining births take place in small health facilities. Tete Provincial Hospital is accessible to patients either directly or through referral from health centers within or outside the city. Recruitment and data collection were performed by four trained research assistants shortly after delivery at all three study sites. Controls were selected in parallel to cases: the first subsequent woman with correct matching criteria was invited to enroll in the control group. Every eligible participant received a personal identification number for use in data collection. A structured face-to-face interview (in the local language) and a review of the medical files (in Portuguese) were conducted to assess prenatal and delivery care. A venous blood sample was taken for laboratory analysis at Tete Provincial Hospital. All instruments were pretested and the principal investigators closely supervised ongoing data collection and laboratory procedures. The interview provided information not routinely recorded in the medical file, including level of education, occupation of the participant and her partner, availability of water and electricity at the participant’s home (subsequently combined into the variable socioeconomic status), smoking, alcohol consumption, height, and weight. The medical files provided all other pertinent information, including medical history and care during pregnancy and childbirth, HIV and syphilis serology, and newborn characteristics. Fetal heartbeat on arrival was determined by auscultation with a Pinard fetoscope on arrival at the health facility of first contact (either one of three study sites or another facility with subsequent referral to a study site). However, a negative fetal heartbeat on arrival at the health facility of first contact did not necessarily reflect prepartum intrauterine death. Many women started labor at home but faced considerable delays before reaching a health facility owing to late recognition of complications while at home, slow decision making to seek professional assistance (which often involved key male relatives), and difficulties in obtaining transport to attend the nearest health facility. Variables related to complications and progress of labor and delivery reflected only events observed within the health system, because medical files did not usually record any events that occurred before admission. Laboratory tests were performed following standardized procedures. Infection with HIV was diagnosed by detection of antibodies using either the Determine HIV-1/2 test (Abbott Laboratories, Chicago, IL, USA) or the Uni-Gold Recombigen HIV-1/2 test (Trinity Biotech, Bray, Ireland). Syphilis was diagnosed by antibody testing and titration using either the Macro-Vue rapid plasma reagin (RPR) card test (BD
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Diagnostics, Sparks, MD, USA) or the SERODIA Treponema pallidum particle agglutination (TPPA) test (Fujirebio Diagnostics, Malvern, PA, USA). Syphilis and HIV tests performed at childbirth complemented the results of tests performed during prenatal care (often at the first visit), because they permitted the identification of seroconversion during pregnancy after starting prenatal care and the titration of syphilis antibodies. Participants were encouraged to collect test results from maternity staff using their personal identification number; any treatment required was administered in accordance with national standards. Quality control of in-house laboratory testing was performed in the national reference laboratory at Maputo for all positive test results and 15% of all negative test results. The required sample size was calculated as 150 cases plus 300 controls, with a confidence interval of 95% and power of at least 80%. These values were based on the reported prevalence of syphilis and HIV in Tete [12,13], with the expectation of at least four-fold (syphilis) and two-fold (HIV) increased seropositivity among the cases than the controls [15–17]. Recruitment continued until the required number of participants for whom all necessary data collection steps (informed consent, interview, medical file review, and laboratory results) had been completed was reached. The number of participants who had completed all the necessary data collection steps was verified; only those with all four steps completed were included in the present analysis. All data were digitized using EPI Info version 3.5.1 (Centers for Disease Control and Prevention, Atlanta, GA, USA). Observations were then validated by double data entry and analyzed using Stata/IC version 11.2 (Stata Corp, College Station, TX, USA). Differences in proportions were calculated using χ2 tests; P b 0.05 was considered statistically significant. Many of the variables examined in the present study were interdependent; therefore, a multivariate analysis was conducted to determine which of the possible explanatory factors influenced the outcome of stillbirth. A conditional logistic regression model was fitted by stepwise elimination of variables that did not contribute significantly to fit (initially taken as P b 0.10, followed by P b 0.05). Sociodemographic factors considered in this model were parity, socioeconomic status (low vs other), residence (in Tete vs outside Tete), and total number of prenatal visits (≥4 vs b4). Obstetric factors were direct complications during pregnancy and childbirth (prolonged labor, ruptured uterus, hemorrhage, preeclampsia, sepsis, and cord complications), indirect complications during pregnancy and childbirth (malaria, anemia, and non-obstetric sepsis), referral during pregnancy and childbirth, instrumental or operative delivery, and level of the attending health professional (medical doctor/ specialist vs other). Additional factors considered were body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters; b18.5 vs ≥18.5) and alcohol use.
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72
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Please cite this article as: Geelhoed D, et al, Risk factors for stillbirths in Tete, Mozambique, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/ j.ijgo.2015.03.027
139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181
184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200
D. Geelhoed et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx Table 1 Characteristics of the study population.a
Age, y Mean (95% confidence interval) Median (range) b20 b ≥35 b Parity 0 1–3 ≥4 Married or in a stable relationship Maternity facility attended Tete Provincial Hospital Health center no 2 Health center no 4
t1:20 t1:21
a
24.7 (23.4–26.2)
P value
24.1 (23.3–24.8)
24 (15–39) 45/149 (30.2) 11/149 (7.4)
24 (15–39) 94/297 (31.6) 21/297 (7.1)
51 (34.0) 47 (31.3) 52 (34.7) 140 (93.3)
102 (34.0) 96 (32.0) 102 (34.0) 287 (95.7)
0.755 0.904 0.992
0.289 N0.99
114 (76.0) 25 (16.7) 11 (7.3)
228 (76.0) 50 (16.7) 22 (7.3)
t2:1 t2:2
Table 2 Factors assumed to be associated with stillbirth.a
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207 208
t2:3
Factor
t2:4 t2:5 t2:6 t2:7 t2:8 t2:9 t2:10 t2:11 t2:12 t2:13 t2:14 t2:15 t2:16 t2:17 t2:18 t2:19 t2:20
Low educational level b Low socioeconomic level c Residence in Tete Regular prenatal care d BMI Range Mean (95% confidence interval) b18.5 ≥30 Smoking during pregnancy Alcohol consumption Positive HIV test result at delivery Positive TPPA syphilis test result at delivery Treatment for acute malaria during pregnancy
t2:21 t2:22 t2:23 t2:24 t2:25 t2:26 t2:27 t2:28
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205 206
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217
pregnancy. Antiretroviral medication for the treatment or prevention of mother-to-child transmission of HIV was administered to 45 (56.3%) women; the remaining 35 (43.7%) women either did not, or probably did not, receive such intervention. Analysis of syphilis testing performed during pregnancy using an unspecified syphilis test suggested that 15 (3.3%) of the 450 women had positive results at this stage. However, syphilis testing at childbirth using either the RPR test or the TPPA test indicated that between 22 (4.9%; RPR) and 27 (6.0%; TPPA) of the women had positive results. Titration of blood samples giving positive RPR or TPPA test results resulted in low titers, suggesting that active syphilis infection was uncommon among the present study cohort. One (2.4%) woman in the control group who tested positive for syphilis at childbirth using both the RPR and the TPPA tests had failed to receive benzathine penicillin on at least one occasion during pregnancy. The highest possible prevalence of syphilis was estimated as 9.3% given the number of women with at least one positive test result at any time during pregnancy or childbirth (i.e. 42 of 450).
Control group (n = 300)
P value
81 (54.0) 77/129 (59.7) 87/150 (58.0) 3/150 (2.0)
126 (42.0) 96/262 (36.6) 258/294 (87.8) 23/266 (8.6)
0.021 b0.001 b0.001 0.007
16.1–39.1 23.0 (22.4–23.5)
15.5–42.5 23.7 (23.1–24.2)
13/149 (8.7) 5/149 (3.4) 0 (0.0) 4 (2.7) 25 (16.7) 6 (4.0)
21/299 (7.0) 33/299 (11.0) 3 (1.0) 27 (9.0) 55 (18.3) 16 (5.3)
0.522 0.006 0.219 0.012 0.663 0.536
4/146 (2.7)
6/268 (2.2)
0.751
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Stillbirth group (n = 150)
Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by the square of height in meters); TPPA, Treponema pallidum particle agglutination. a Values given as number (percentage) or number/number for whom data were available, unless indicated otherwise. b No formal education or incomplete primary school education. c No formal education or incomplete primary school education, non-skilled occupations of participant and her partner, and neither water nor electricity connections at home. d Four or more visits distributed over all three trimesters, as recommended in national guidelines.
4. Discussion
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The present study provided evidence that the high institutional stillbirth rate recorded in the Mozambican town of Tete City [11] largely reflects direct obstetric complications, particularly among women of low socioeconomic status and those who commence skilled care during childbirth in a peripheral health facility with subsequent referral. Overall, 33.3%–53.3% of stillbirths in the present study period occurred during labor or delivery after arrival at the health facility of first contact, during transfer, or at the referral hospital. Such outcomes might be prevented through improved provision of emergency obstetric care [18]. The observed pattern of emergency obstetric care suggested a paradox in the health system in Tete City. In many cases, cesareans were conducted to deliver neonates already dead on arrival—although some of these procedures might have been unavoidable owing to severe maternal complications, such as ruptured uterus. By contrast, few cesareans were performed to deliver live neonates. This finding suggested the need for cesarean delivery has been poorly defined, as has been reported previously in Tanzanian hospitals [19]. Neither syphilis nor HIV was significantly associated with an outcome of stillbirth in the present study, despite considerable prevalence and the introduction of screening and treatment in prenatal care in 2002. It appears that these infections were diagnosed and treated sufficiently to avoid its sequels in the fetus. In the case of prenatal syphilis diagnosis and treatment, the benefits for fetal survival have been well documented, but the benefits of HIV diagnosis and treatment are less certain [20,21]. Nevertheless, diagnosis and management of HIV were still far from satisfactory considering mother and child health in general. Only 72.5% of all women with HIV were diagnosed during or before pregnancy and just 56.3% received any antiretroviral medication. Further improvements in HIV testing during pregnancy and childbirth are obviously required, as are improvements in the provision of medication for maternal health and prevention of mother-to-child transmission. As reported elsewhere [2,6], the known limitations of the local health system were likely to be the underlying cause for the prevalence of fetal death in Tete. Data on availability of staff, equipment, medication, cars for emergency referrals, and other features of the health system were not collected in the present study. However, improvements in the quality of emergency obstetric care services are obviously required to address the high stillbirth rate in Tete [14,22,23]. Many interventions that could feasibly be implemented in this setting have proven efficacious for achieving such improvements [24–28]. These interventions include correct and consistent use of the partogram—a graphic record of progress of labor against time elapsed, detailing cervical dilatation, descent of the presenting part, frequency and strength of contractions, and vital signs of mother and fetus—for the timely
P
Values given as number (percentage) unless indicated otherwise. Values are given as number/number for whom data are available (percentage).
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b
Control group (n = 300)
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t1:4 t1:5 t1:6 t1:7 t1:8 t1:9 t1:10 t1:11 t1:12 t1:13 t1:14 t1:15 t1:16 t1:17 t1:18 t1:19
Stillbirth group (n = 150)
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Characteristic
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t1:3
Direct obstetric complications at childbirth, emergency obstetric care, and mode of delivery were significantly different between the two groups (Table 3). Direct obstetric complications—prolonged labor, ruptured uterus, prepartum hemorrhage, and obstetric sepsis—occurred more frequently in the stillbirth group than the control group (P b 0.001 for all). Cord complications were also more frequent in the stillbirth group than the control group (P b 0.001). Probably as a consequence of these complications, more women in the stillbirth group had been referred from a peripheral health facility to Tete Provincial Hospital during childbirth (P b 0.001). Significantly more women in this group than in the control group underwent cesarean delivery, hysterectomy, blood transfusion, and treatment with antibiotics (P b 0.001 for all). Vacuum extraction and intravenous oxytocin were rarely used in either group. After stepwise removal of variables least contributing to fit, direct obstetric complications (mutually adjusted odds ratio [OR] 6.7; 95% confidence interval [CI] 3.6–12.1), referral during childbirth (mutually adjusted OR 3.2; 95% CI 1.7–6.1), and low socioeconomic level (mutually adjusted OR 1.8; 95% CI 1.1–3.1) were all found to contribute to the observed variability in between-group fetal outcomes.
E
t1:1 t1:2
3
Please cite this article as: Geelhoed D, et al, Risk factors for stillbirths in Tete, Mozambique, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/ j.ijgo.2015.03.027
220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236
238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281
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D. Geelhoed et al. / International Journal of Gynecology and Obstetrics xxx (2015) xxx–xxx
Table 3 Characteristics of obstetric complications and care.a Characteristic
Stillbirth group (n = 150)
Control group (n = 300)
P value
t3:4 t3:5 t3:6 t3:7 t3:8 t3:9 t3:10 t3:11 t3:12 t3:13 t3:14 t3:15 t3:16 t3:17 t3:18 t3:19 t3:20 t3:21 t3:22
Direct obstetric complications Prolonged labor b Ruptured uterus (as recorded in the medical file) Prepartum hemorrhage (as recorded in the medical file) Pre-eclampsia and/or eclampsia c Sepsis owing to obstetric causes, including chorioamnionitis (as recorded in the medical file) Cord complications, including prolapse (as recorded in the medical file) Malpresentation (as recorded in the medical file) Referral from a peripheral health center to Tete Provincial Hospital during labor or delivery Instrumental or operative childbirth Caesarean delivery Hysterectomy Vacuum extraction Oxytocin administered intravenously during labor or delivery Antibiotic treatment Blood transfusion Anticonvulsive treatment Antihypertensive treatment Traditional treatment d
110/147 (74.8) 66 (44.0) 17 (11.3) 21 (14.0) 9/149 (6.0) 12 (8.0) 22 (14.7) 7 (4.7) 62 (41.3) 68 (45.3) 64 (42.7) 9 (6.0) 4/149 (2.7) 3 (2.0) 51 (34.0) 20 (13.3) 6 (4.0) 2 (1.3) 1 (0.7)
83/287 (28.9) 44 (14.7) 0 (0.0) 3 (1.0) 18/288 (6.3) 3/299 (1.0) 1 (0.3) 6 (2.0) 32/297 (10.8) 53 (17.7) 50 (16.7) 0 (0.0) 3 (1.0) 8 (2.7) 40 (13.3) 2 (0.7) 9 (3.0) 3 (1.0) 7 (2.3)
b0.001 b0.001 b0.001 b0.001 0.931 b0.001 b0.001 0.111 b0.001 b0.001 b0.001 b0.001 0.175 0.666 b0.001 b0.001 0.577 0.750 0.207
t3:23 t3:24 t3:25 t3:26
a
310
Acknowledgments
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The Flemish International Cooperation Agency funded the present study as part of the Integrated Network for the Fight Against HIV/AIDS/ STI in Tete Province, Mozambique project. Additional financial support was provided by the Program for Inter-University Collaboration of Eduardo Mondlane University, Mozambique, and the Flemish Inter-University Council, which is funded by the Belgium Development Cooperation.
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Conflict of interest
296 297 298 299 300 301 302 303 304 305 306 307 308
312 313 314 315
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diagnosis and referral of cases of prolonged labor during the latent and active phases of labor. Improved systems for communication and collaboration between the referring center and referral health facilities is also essential, including provision of a fleet of well maintained vehicles for transport of patients between sites. Consistent adherence to national protocols for emergency obstetric care should be enhanced through the use of regular emergency care drills to improve practical skills of midwives. Supportive supervision of labor wards, investments in personnel and equipment, and improved supply chain management are also indispensable. Constructive audit of maternal and neonatal complications and deaths, introduced in Mozambique since 2010, will aid identification and mitigation of persisting systematic weaknesses. Beyond the lack of data collection on health system failings, the present study was limited in that it only involved women within the health system of Tete. Often, it was impossible to identify whether the stillbirth had occurred prepartum or intrapartum. This distinction is important because prepartum stillbirths tend to be caused by maternal disease or growth retardation, whereas intrapartum stillbirths often reflect obstetric complications. In addition, risk factors for stillbirth might be different between women from Tete, who live close to a health facility and often have a high socioeconomic status, and women living in the surrounding areas. Unfortunately, the sample size was insufficient to perform additional analyses for these subgroups. In conclusion, findings on risk factors for stillbirth in Tete were largely in line with those previously reported. The present study has provided valid evidence to suggest that emergency obstetric care and referral systems should be the focus for future interventions aimed at stillbirth prevention in Mozambique.
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Values given as number (percentage) or number/number for whom data were available, unless indicated otherwise. Active first stage of labor lasting N6 h or second stage of labor lasting N1 h. Diastolic blood pressure ≥90 mm Hg (or an increase of 15 mm Hg) and/or systolic blood pressure ≥140 mm Hg (or an increase of 30 mm Hg), with or without convulsions. Unspecified non-medically prescribed treatment, according to the local cultural traditions.
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The authors have no conflicts of interest.
Please cite this article as: Geelhoed D, et al, Risk factors for stillbirths in Tete, Mozambique, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/ j.ijgo.2015.03.027
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[19] Maaløe N, Sorensen BL, Onesmo R, Secher NJ, Bygbjerg IC. Prolonged labour as indication for emergency caesarean section: a quality assurance analysis by criterionbased audit at two Tanzanian rural hospitals. BJOG 2012;119(5):605–13. [20] Hawkes S, Matin N, Broutet N, Low N. Effectiveness of interventions to improve screening for syphilis in pregnancy: a systematic review and meta-analysis. Lancet Infect Dis 2011;11(9):684–91. [21] Ishaque S, Yakoob MY, Imdad A, Goldenberg RL, Eisele TP, Bhutta ZA. Effectiveness of interventions to screen and manage infections during pregnancy on reducing stillbirths: a review. BMC Public Health 2011;11(Suppl. 3):S3. [22] Pattinson R, Kerber K, Buchmann E, Friberg IK, Belizan M, Lansky S, et al. Stillbirths: how can health systems deliver for mothers and babies? Lancet 2011;377(9777): 1610–23. [23] Bhutta ZA, Yakoob MY, Lawn JE, Rizvi A, Friberg IK, Weissman E, et al. Stillbirths: what difference can we make and at what cost? Lancet 2011;377(9776):1523–38.
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Please cite this article as: Geelhoed D, et al, Risk factors for stillbirths in Tete, Mozambique, Int J Gynecol Obstet (2015), http://dx.doi.org/10.1016/ j.ijgo.2015.03.027
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