Risk factors for stillbirths: how much can a responsive health system prevent?

BMC Pregnancy Childbirth. 2018 Jan 18;18(1):33. doi: 10.1186/s12884-018-1660-1.


Background: The stillbirth rate is an indicator of quality of care during pregnancy and delivery. Good quality care is supported by a functional heath system. The objective of this study was to explore the risk factors for stillbirths, particularly those related to a health system.

Methods: This case-control study was conducted in two districts of Bihar, India. Information on cases (stillbirths) were obtained from facilities as reported by Health Management Information System; controls were consecutive live births from the same population as cases. Data were collected from 400 cases and 800 controls. The risk factors were compared using a hierarchical approach and expressed as odds ratio, attributable fractions and population attributable fractions.

Results: Of all the factors studied, 22 risk factors were independently associated with stillbirths. Health system-related factors were: administration of two or more doses of oxytocics to augment labour before reaching the facilities (OR 1.6; 95% CI 1.2-2.1), any complications during labour (OR 2.3;1.7-3.1), >30 min to reach a facility from home (OR 1.4;1.05-1.8), >10 min to attend to the pregnant woman after reaching the facility (OR 2.8;1.7-4.5). In the final regression model, modifiable health system-related risk factors included: >10 min taken to attend to women after they reach the facilities (AOR 3.6; 95% CI 2.5-5.1), untreated hypertension during pregnancy (AOR 2.9; 95% CI 1.5-5.6) and presence of any complication during labour, warranting treatment (AOR 1.7; 95% CI 1.2-2.4). Among mothers who reported complications during labour, time taken to reach the facility was significantly different between stillbirths and live births (2nd delay; 33.5 min v/s 25 min; p < 0.001). Attributable fraction for any complication during labour was 0.56 (95% CI 0.42-0.67), >30 min to reach the facility 0.48 (95% CI 0.31-0.60) and institution of management 10 min after reaching the facility 0.68 (95% CI 0.58-0.75). Reaching a facility within 30 min, initiation of management within 10 min of reaching the facility and timely management of complications during labour could have prevented 17%, 37% and 20% of stillbirths respectively.

Conclusion: A pro-active health system with accessible, timely and quality obstetric services can prevent a considerable proportion of stillbirths in low and middle income countries.

Keywords: Health systems; Low and middle income countries; Risk factors; Stillbirths.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Case-Control Studies
  • Female
  • Health Services Accessibility / statistics & numerical data
  • Humans
  • India / epidemiology
  • Obstetric Labor Complications / etiology*
  • Obstetric Labor Complications / prevention & control
  • Poverty / statistics & numerical data
  • Pregnancy
  • Prenatal Care / standards
  • Prenatal Care / statistics & numerical data*
  • Quality of Health Care
  • Regression Analysis
  • Risk Factors
  • Stillbirth / epidemiology*
  • Time-to-Treatment / standards
  • Time-to-Treatment / statistics & numerical data