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Risk factors for antepartum stillbirth: a case-control study in Nepal
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Pediatrics.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, International Maternal and Child Health (IMCH).
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2015 (English)In: BMC Pregnancy and Childbirth, ISSN 1471-2393, E-ISSN 1471-2393, Vol. 15, 146Article in journal (Refereed) Published
Abstract [en]

Background: Globally, at least 2.65 million stillbirths occur every year, of which more than half are during the antepartum period. The proportion of intrapartum stillbirths has substantially declined with improved obstetric care; however, the number of antepartum stillbirths has not decreased as greatly. Attempts to lower this number may be hampered by an incomplete understanding of the risk factors leading to the majority of antepartum stillbirths. We conducted this study in a tertiary hospital in Nepal to identify the specific risk factors that are associated with antepartum stillbirth in this setting. Methods: This case-control study was conducted between July 2012 and September 2013. All women who had antepartum stillbirths during this period were included as cases, while 20 % of all women delivering at the hospital were randomly selected and included as referents. Information on potential risk factors was taken from medical records and interviews with the women. Logistic regression analysis was completed to determine the association between those risk factors and antepartum stillbirth. Results: During the study period, 4567 women who delivered at the hospital were enrolled as referents, of which 62 had antepartum stillbirths and were re-categorized into the case population. In total, there were 307 antepartum stillbirths. An association was found between the following risk factors and antepartum stillbirth: increasing maternal age (aOR 1.0, 95 % CI 1.0-1.1), less than five years of maternal education (aOR 2.4, 95 % CI 1.7-3.2), increasing parity (aOR 1.2, 95 % CI 1.0-1.3), previous stillbirth (aOR 2.6, 95 % CI 1.6-4.4), no antenatal care attendance (aOR 4.2, 95 % CI 3.2-5.4), belonging to the poorest family (aOR 1.3, 95 % CI 1.0-1.8), antepartum hemorrhage (aOR 3.7, 95 % CI 2.4-5.7), maternal hypertensive disorder during pregnancy (aOR 2.1, 95 % CI 1.5-3.1), and small weight-for-gestational age babies (aOR 1.5, 95 % CI 1.2-2.0). Conclusion: Lack of antenatal care attendance, which had the strongest association with antepartum stillbirth, is a potentially modifiable risk factor, in that increasing the access to and availability of these services can be targeted. Antenatal care attendance provides an opportunity to screen for other potential risk factors for antepartum stillbirth, as well as to provide counseling to women, and thus, helps to ensure a successful pregnancy outcome.

Place, publisher, year, edition, pages
2015. Vol. 15, 146
Keyword [en]
Antepartum stillbirth, Risk factors, Nepal
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
URN: urn:nbn:se:uu:diva-259090DOI: 10.1186/s12884-015-0567-3ISI: 000357372700001OAI: oai:DiVA.org:uu-259090DiVA: diva2:843509
Available from: 2015-07-29 Created: 2015-07-27 Last updated: 2017-12-04Bibliographically approved
In thesis
1. Neonatal Resuscitation: Understanding challenges and identifying a strategy for implementation in Nepal
Open this publication in new window or tab >>Neonatal Resuscitation: Understanding challenges and identifying a strategy for implementation in Nepal
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Despite the unprecedented improvement in child health in last 15 years, burden of stillbirth and neonatal death remain the key challenge in Nepal and the reduction of these deaths will be crucial for reaching the health targets for Sustainable development goal by 2030.

The aim of this thesis was to explore the risk factors for stillbirth and neonatal death and change in perinatal outcomes after the introduction of the Helping Babies Breathe Quality Improvement Cycle (HBB QIC) in Nepal.

This was a prospective cohort study with a nested case-control design completed in a tertiary hospital in Nepal. Information were collected from the women who had experienced perinatal death and live birth among referent population; a video recording was done in the neonatal resuscitation corner to collect information on the health workers’ performance in neonatal resuscitation. 

Lack of antenatal care had the highest association with antepartum stillbirth (aOR 4.2, 95% CI 3.2–5.4), births that had inadequate fetal heart rate monitoring were associated with intrapartum stillbirth (aOR 1.9, CI 95% 1.5–2.4), and babies who were born premature and small-for-gestational-age had the highest risk for neonatal death in the hospital (aOR 16.2, 95% CI 12.3–21.3). Before the introduction of the HBB QIC, health workers displayed poor adherence to the neonatal resuscitation protocol. After the introduction of HBB QIC, the health workers demonstrated improvement in their neonatal resuscitation skills and these were retained until six months after training. Daily bag-and-mask skill checks (RR 5.1 95% CI 1.9–13.5), preparation for birth (RR 2.4, 95% CI 1.0–5.6), self-evaluation checklists (RR 3.8, 95% CI 1.4–9.7) and weekly review and reflection meetings (RR 2.6, 95% 1.0–7.4) helped the health workers to retain their neonatal resuscitation skills. The health workers demonstrated improvement in ventilation of babies within one minute of birth and there was a reduction in intrapartum stillbirth (aOR 0.46, 95% CI 0.32–0.66) and first-day neonatal mortality (aOR 0.51, 95% CI 0.31–0.83). 

The study provides information on challenges in reducing stillbirth and neonatal death in low income settings and provides a strategy to improve health workers adherence to neonatal resuscitation to reduce the mortality. The HBB QIC can be implemented in similar clinical settings to improve quality of care and survival in Nepal, but for primary care settings, the QIC need to be evaluated further.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2016. 83 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1166
Keyword
antepartum stillbirth, intrapartum stillbirth, neonatal mortality, first-day neonatal mortality, antenatal care, fetal heart rate monitoring, partogram, preterm, small-for-gestational-age, clinical adherence, neonatal resuscitation, skill retention, quality improvement cycle, Nepal
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
International Health
Identifiers
urn:nbn:se:uu:diva-267917 (URN)978-91-554-9434-6 (ISBN)
Public defence
2016-02-10, Museum Gustavianum, Akademigatan 3, Uppsala, 09:00 (English)
Opponent
Supervisors
Available from: 2016-01-20 Created: 2015-11-29 Last updated: 2016-02-12

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K.C, AshishWrammert, JohanEwald, UweMålqvist, Mats

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