Incidence of Stillbirth in Relation to Period of Delivery, Socioeconomic Status and Period of Gestation in a Rural Tertiary Care Hospital-MGIMS, Sewagram Within Study Period of Three Years (2013–2016)

Abstract

Background

Stillbirth remains one of the most common adverse outcomes of pregnancy, yet is among the least studied. Occurrence of stillbirth is a tragic event faced by mother as well as obstetrician. It has implications on couple, their family and the health care providers. It reflects a failure or lapse in implementation of maternal and child health care programs. Worldwide 3.2 million stillbirth occur in world, 20–66 per 1000 total births in India in different states. Stillbirth in India is largely underreported. Stillbirths contribute to more than half of perinatal death. More than 2/3rd Stillbirth take place during pregnancy and remaining during course of labour. Registration of all live births and stillbirths, together with evaluation of cause of stillbirths are important initial steps for developing countries. A standard classification system would be important to document aetiology of stillbirth in developing countries.

The Methodology was as Following

All cases who delivered a stillborn baby in the hospital were studied in details. The records were maintained date-wise. Initially, the basic demographic information was taken giving special attention to age, education, occupation, socioeconomic status, rural or urban residence etc. The two controls of live births were also asked the same details and the data were entered in Microsoft word excel sheet and analyzed by Chi-square test.

Conclusion

Incidence of stillbirth in MGIMS Sewagram which is Tertiary care centre placed in rural area was 30.57%. Incidence in relation to place (rural) 62.42%, more in antepartum 94.9% (149/157), in low socioeconomic status 48%. It was found more in 30–32 weeks of period of gestation as in this period most of medical disorders of pregnancy precipitate.

Supplementary Information

The online version of this article (10.1007/s13224-021-01453-6) contains supplementary material, which is available to authorized users.

The Methodology was as Following

All the cases who delivered a stillborn baby in the hospital were studied in details. The records were maintained date-wise. Initially the basic demographic information were taken giving special attention to age, education, occupation, socioeconomic status, rural or urban residence etc.

The two controls of live births were also asked the same details and the data was entered in Microsoft word excel sheet and analyzed by Chi square test (Table 1).

Table 1.

Distribution of still births according to gestational age and its type

Residence	Gestational age	Still birth				Total still birth
		Fresh		Macerated		No.	%
		No.	%	No.	%
Rural (62.42)	Early (20–28 weeks)	10	38.46	16	38.46	26	100
	Late (> 28 weeks)	22	30.56	50	30.56	72	100
Urban (37.58)	Early (20–28 weeks)	1	12.5	7	12.5	8	100
	Late (> 28 weeks)	15	29.41	36	29.41	51	100
Total		48	30.57	109	69.43	157	100

Observations

The Following Tables Describe our Results

The total no of still births during the study period were 157, out of which fresh still births 48 (30.57%) and macerated 109 (69.43%), 98 (62.42%) women from rural setting (p – 0.0007)and 59 (37.58%) from urban area.. Late still births were 123 (78.34%) with significant P value of 0.0007 when compared with early still births in both rural as well as urban settings. Macerated late still birth were almost double the fresh still births (Table 2).

Table 2.

Distribution of still birth according to stages of pregnancy

Phase of still births	As per gestational age	Fresh		Macerated		Total still births
		No.	%	No.	%	No.	%
Antepartum	Early	6	12.50	23	21.10	29	18.47
	Late	34	70.83	86	78.90	120	76.43
Intrapartum	Early	5	10.42	0	00	05	3.18
	Late	3	6.25	0	00	3	1.91
Total	48	100	109	100	157	100

Antepartum deaths were 149 (94.90%), intrapartum deaths were 8 (5.10%). There were several disorders causing antepartum deaths and many women had multiple disorders. Out of 8 intrapartum deaths, 5 during early gestations due to preterm labour and placental abruption and 3 in late gestation due to cord round neck, true knot and intrapartum abruption.

On looking into socioeconomic status as per modified Prasad classification 48% of women were from lower socioeconomic status (Table 3).

Table 3.

Distribution still births according to gestational age

Residence	Type of still birth	Gestational age	Total still birth				Total
			Fresh		Macerated
			No.	%	No.	%
Rural	Early (20–28 weeks)	20 to  < 24 weeks	4	40	6	60	10
		24 to  < 28 weeks	6	37.5	10	62.5	16
	Late (> 28 weeks)	28 to  < 30 weeks	8	57.14	6	42.86	14
		30 to  < 32 weeks	12	33.33	24	66.67	36
		32 to  < 34 weeks	1	14.29	6	85.71	7
		34 to  < 37 weeks	0	00	8	100	8
		> 37 weeks	1	14.29	6	85.71	7
Urban	Early (20–28 weeks)	20 to  < 24 weeks	1	20	4	80	5
		24 to  < 28 weeks	0	00	3	100	3
	Late (> 28 weeks)	28 to  < 30 weeks	6	40	9	60	15
		30 to  < 32 weeks	8	44.44	10	55.56	18
		32 to  < 34 weeks	1	12.5	6	87.5	7
		34 to  < 37 weeks	0	00	6	100	6
		> 37 weeks	0	00	8	100	8
Total	48		109		157

The total no of births during the study period were 6650 (total live as well as still births).

Calculation of still births rate and ratio

$$\text{Stillbirth rate}=\frac{\text{Total No. of still births}}{\text{Total No. of birth}\left(\text{total live birth + still birth}\right)}\times 1000=\frac{157}{6650}\times 1000=23.61$$

$$\text{Stillbirth rate}=\frac{\text{Total No. of still births}}{\text{Total No. of live birth}}\times 1000=\frac{157}{6493}\times 1000=24.17$$

It was observed that most of the late still births occurred between 30 and 32 weeks. 50% (36) late stillbirth in rural group as compared to urban group 35% (18).

Disscussion

Stillbirth is a tragic event faced by the mother as well as her obstetrician and is certainly reducible in large number. Registration of all live births and stillbirths, together with evaluation of cause of stillbirths are important initial steps for developing countries [1]. In order to understand stillbirth rates and causes standard classification system would be important to document the etiology of stillbirth in developing countries. Finally, access to appropriate essential obstetric care and planned interventions shall significantly reduce global stillbirth rates.

The present study was conducted in Obstetrics and Gynaecology Department of rural tertiary care hospital of Central India as an attempt to know incidence of stillbirth in relation to period of delivery, socioeconomic status and period of gestation with the study period of three years (2013–2016) in order to identify gaps and improvise system to further reduce stillbirth rate.

The still birth rate during our study period was 23.61% and still birth ratio was 24.17. According to Cousens et al. [2] the census states that the still birth rate of India presently is 22 and has reduced from 25 in 1995 till date with the annual reduction rate of one.

More stillbirth 62.42% from rural population as our institute is located in the rural area constituting around 60–70%. In a study by Saxena et al. [3] the vital registration data on perinatal deaths especially still births is inadequate in India. Medically certified causes of death for stillbirth are not clear in rural areas as majority of these deaths occur at home. Even if death occurs in hospital death certificate is seldom issued. In study by Reeske et al. [4] the figures, using government data and statistical extrapolation, put the global rate of stillbirths at 19 for every 1000 births. India is in the top half of the chart with 22 still births per 1000 in a spectrum, Pakistan and Nigeria at 40 per 1000 and Finland at two per 1000.

Fresh still births where during antenatal period there was sudden disappearance of fetal heart rate which was recently there or if the baby born had shown features of fresh intrauterine death with no apparent signs of maceration. Macerated stillborns were those in whom ultrasonographic signs of maceration were there or the baby born had apparent signs of maceration. The diagnosis in antepartum stillborn case was done there and then as many a times even though the death was antepartum and was diagnosed during antenatal period, but by the time the women delivered the baby became macerated. Such deaths were considered in fresh deaths as diagnosis was during antenatal period when the baby had freshly died.

According to the annual stillbirth ratio at HMH was 56 per 1000 total births, of which 12 per 1000 were fresh stillbirths, 27 per 1000 were macerated stillbirths, and 17 per 1000 were for stillbirths whose type was not indicated in the obstetric records. [5] In another study conducted by Stanton et al. [1] a ratio of intrapartum to antepartum stillbirth was nearly 1:5 for high-income countries and 1:2 for low-income countries. The ratios of fresh to macerated stillbirths may reflect the quality of prenatal and obstetric care, with high ratios implying poorer care. [6] Supporting this, Goldenberg et al. [7] assessed the relationship between provision of emergency obstetric services using cesarean deliveries as proxy values, and intrapartum and antepartum stillbirths. They depicted a linear relationship on a scatterplot of intrapartum (fresh) stillbirths and provision of obstetric services, when compared with that of antepartum stillbirths and provision of obstetric services. Furthermore, there was a dramatic decrease in intrapartum stillbirth rates when cesarean delivery rates increased from 0 to 10% (Figs. 1, 2, 3).

Fig. 1.

Distribution of still births according to gestational age and its type

Fig. 2.

Distribution of still birth according to stages of pregnancy

Fig. 3.

Distribution still births according to gestational age

In a another study conducted by Engmann et al. [8], a surprising finding was that the ratio of fresh to macerated stillbirths was nearly 4:1. Fresh stillbirths are used as a proxy for stillbirths due to acute intrapartum insults. [9], Lawn et al. [10] estimated intrapartum stillbirth using data from 52 countries with a cumulative sample size of 46 779 stillbirths. In their model they estimated there were 1.02 million intrapartum (fresh) stillbirths out of a total of 3.9 million, resulting in a ratio of fresh to macerated stillbirths of 1:3. Similar ratios have been noted in the literature [6]. Lawn et al. [10] noted wide disparities in intrapartum stillbirth rates when comparing regions with the highest and lowest rates. Countries in the Western Pacific, northwest Europe, and North Americas had intrapartum stillbirth rates of less than 1 per 1000 total births, while countries in Sub-Saharan Africa and South East Asia had rates 15 times higher. There was a 50-fold difference when they compared the lowest (0.33 per 1000 total deaths) and highest (17.4 per 1000 total births) reported stillbirth rates. Goldenberg et al. [7] compared the ratio of intrapartum to antepartum stillbirth in low- and high-income countries using Lawn’s estimations of intrapartum deaths and overall stillbirth estimates from Stanton et al. [1] they found a ratio of intrapartum to antepartum stillbirth of nearly 1:5 for high-income countries and 1:2 for low-income countries. The ratios of fresh to macerated stillbirths may reflect the quality of prenatal and obstetric care, with high ratios implying poorer care. [6] Supporting this, Goldenberg et al. [7] assessed the relationship between provision of emergency obstetric services using cesarean deliveries as proxy values, and intrapartum and antepartum stillbirths. They depicted a linear relationship on a scatterplot of intrapartum (fresh) stillbirths and provision of obstetric services, when compared with that of antepartum stillbirths and provision of obstetric services. Furthermore, there was a dramatic decrease in intrapartum stillbirth rates when cesarean delivery rates increased from 0 to 10%.

Similar ratio of fresh to macerated stillbirths was found from our data too. McClure et al. [9] reported on the outcome of 60,324 pregnancies resulting in 1472 stillbirths in 5 low-income countries and 1 middle-income country, and found ratios of fresh to macerated stillbirths of nearly 5:1, which is also consistent with our data. The public health ramification of higher fresh to macerated stillbirth ratios is that fresh stillbirths are amenable to interventions that are likely to result in improved outcomes [11].

In our study macerated still births were more at term. 8 macerated stillbirth were of term gestationand none fresh. But in study conducted by Melissa et al. [12] the risk of stillbirth at term increases with gestational age from 2.1 per 10,000 ongoing pregnancies at 37 weeks of gestation up to 10.8 per 10,000 ongoing pregnancies at 42 weeks of gestation.

The low rate of intrapartum deaths in our study can be explained by the modifications done in the labour room monitoring system. We have a separate team, E PARTOGRAM for monitoring labour which can be accessed online anywhere by unit incharges even, while they are in their offices so they can monitor their patient’s partogram and can advise/guide immediately in case of any adverse complication.

Conclusion

• Incidence of stillbirth in MGIMS Sewagram which is Tertiary care centre placed in rural area was 30.57%. Inrelation to place (rural) 62.42%, more in antepartum 94.9% (149/157), in low socioeconomic status 48%. It was found more in 30–32 weeks of period of gestation as in this period most of medical disorders of pregnancy precipitate.

• More still births occurred in women from rural habitat compared to urban settings. Late still births were more common.

Shila Pandurang Shelke

is working as Assistant Professor OBGY since 2013. She did DGO in MGIMS, Sewagram and secondary DNB OBGY in Rural Development Trust Hospital Bathalapalli, Andhrapradesh. Is involved in various social activities, present FOGSI (Sewagram Obstetrics and Gynaecology Society) Secretary. Is involved in various academic activities in MGIMS, Sewagram. Has been involved in various departmental project. Has done NELS and ICMR Genetic counselling course, Obstetric sonology course. Has done oncology observership in Vaidehi Institute of Medical Sciences. Presently working as Associate Professor im MGIMS, Sewagram.

Funding

No funding sources.

Compliance with Ethical Standards

Conflict of interest

The authors declared that they have no conflict of interest.

Ethical Approval

The study was approved by the Institutional Ethics Committee in MGIMS, Sewagram.