Background
Pregnancy loss is a collective term used to describe pregnancies that failed to produce a live birth. The losses can occur anytime during the course of pregnancy. A stillbirth is characterized as the demise of the embryo in the uterus before birth at or following 28 weeks’ incubation. Intrauterine demise can happen either earlier or amid work [
1]. Following the development in neonatal intensive care, the definition has changed and varies between countries. In high-income countries, like Norway, a newborn can survive after 25 weeks’ gestation, compared to 28–32 weeks’ gestation in low resource countries. In many low resource countries, preterm babies with no life expectancy outside the womb, therefore die intrauterine without any attempt at rescue.
The stillbirth rate for developed nations is predicted between 4.2 and 6.8per thousand births, whereas for the developing countries, it is estimated as 20 to 32 per thousand births. Sixty-six percent of all stillbirths occur in only regions such as Africa and South-East Asia [
2]. In sub-Saharan Africa, an expected amount, 900,000 pregnancy experienced stillbirth. Stillbirths occurrence varies greatly among countries [
3]. For example, countries with less knowledge on preventing stillbirths, give stillbirths low national priority [
4]. In Ethiopia, the world health statistics 2013 showed a stillbirth rate of 26 per thousand deliveries that makes it the third maximum rate in the east African nations next to Djibouti and Somalia (with stillbirth costs of 34 and 30 per 1000 births, respectively) [
5]. The Ethiopian Demographic and Health Survey (DHS) 2005 data showed that the still birth rate is 18 for each 1000 births [
6].
Every year, nearly 3 million third trimester stillbirths happen globally with 98% in low and middle-income countries (LMIC) [
7]. Interventions to reduce stillbirths are not often evaluated, and those studies of enhancing maternal and new child fitness have rarely covered the evaluation of their effect on stillbirth. Though, stillbirth is not recognized as a fitness problem, either in worldwide health metrics or in specific context, most LMIC data report the stillbirth cases [
1]. Yet stillbirths are invisible in international fitness monitoring. Unlike other unfavorable pregnancy outcomes (including maternal and neonatal mortality), stillbirth is not always formally included in any of the most important global sickness campaigns [
4]. That is, if a pregnancy final result is not counted, it will almost definitely be ignored by the investment companies, policy makers, and neighborhood communities. There is also a giant fatalism that those toddlers who die of utero have never been intended to stay. Even the stigmatization of ladies who have given birth to a dead toddler is unfair, merciless and not based on facts. Besides, the point fatalism concerning stillbirths among care givers and policy makers will actually guarantee that no development happens. Hence, fitness professionals, and lots of ladies for whom they offer care consider stillbirth a good deal more than is typically perceived, but the topic is not often discussed in the media, or by means of policy makers [
8]. In addition, stillbirths are regularly no longer registered systematically in lots of low-income countries like Ethiopia, and reliable registrations exist only in countries with minor quantity of deaths. This leads to underestimation of stillbirths in those countries, where 98% of all stillbirths occur [
1].
In general, the invisibility of stillbirths is complicated and deeply rooted in social constructs of personhood in high mortality settings including Amhara region, Ethiopia. For example, blame and stigma, in addition to the prevalence of home delivery and the shortage of a national vital registration system, contribute to the invisibility of stillbirths. Acknowledging stillbirth while it occurs requires each nearby and country wide reaction, along with the development of a national vital registration system, health system policies, and behavior-change communication interventions.
Based on the aforementioned rationale, this study aimed to determine the prevalence and associated factors of stillbirth outcomes of pregnancy.
Results
In this study, a total of 2555 women were involved. The results of this study are presented in three tables. Table
1 shows the demographic characteristics. Table
2 states the obstetrics related characteristics and Table
3 has medical related characteristics.
Table 1
Socio-demographic characteristics of sampled women, Amhara Region Ethiopia
Residence |
Urban | 164 | 6.4 |
Rural | 2391 | 93.6 |
Age |
< 24 | 178 | 7.0 |
25–34 | 903 | 35.3 |
35+ | 1474 | 57.7 |
Marital Status |
Married | 2184 | 85.5 |
Othera
| 371 | 14.5 |
Educational Level |
No education | 2131 | 83.4 |
Primary and Above | 424 | 16.6 |
Wealth Index |
Poor | 1254 | 49.1 |
Middle | 752 | 29.4 |
Rich | 549 | 21.5 |
Age at First Birth |
Below 18 | 1859 | 72.8 |
Above 18 | 696 | 27.2 |
Family Size |
Below 5 | 1072 | 42.0 |
Above 5 | 1483 | 58.0 |
Birth Order Number |
First | 604 | 23.6 |
Second | 510 | 20.0 |
Third and Above | 1441 | 56.4 |
Table 2
Obstetrics related characteristics of sampled women in Amhara Region Ethiopia
Did you attend antenatal care? |
No | 2313 | 90.5 |
Yes | 242 | 9.5 |
Number of Antenatal care Visits |
No Visit | 147 | 38.1 |
1+ | 239 | 61.9 |
Time of first Antenatal Care visit |
1st trimester | 58 | 24.5 |
2nd trimester | 124 | 52.3 |
3rd trimester | 55 | 23.2 |
Modern Contraceptive Used Prior to Current Pregnancy |
No | 1621 | 63.4 |
Yes | 934 | 36.6 |
Type of Contraceptive Used |
Not Using | 1594 | 62.4 |
Injections | 758 | 29.7 |
Otherb
| 203 | 7.9 |
Place of Delivery |
Home | 465 | 88.4 |
Health Center | 61 | 11.6 |
Preceding Birth Interval in Months |
< 24 | 897 | 46.0 |
25–36 | 540 | 27.7 |
36+ | 512 | 26.3 |
Table 3
Medical related characteristics of sampled women in Amhara Region Ethiopia
Stillbirth Outcomes |
No | 2337 | 91.5 |
Yes | 218 | 8.5 |
Signs of pregnancy complications (vaginal bleeding and gush of fluid, severe head ache, blurred vision, fever, abdominal pain, swollen legs, other) |
No | 2515 | 98.4 |
Yesb
| 40 | 1.6 |
Blood Pressure |
No | 80 | 33.1 |
Yes | 162 | 66.9 |
During pregnancy, given or bought iron tablets/syrup |
No | 230 | 59.0 |
Yes | 160 | 41.0 |
As Table
1 shows, only 6% of women aged 15–49 were from urban areas and more than half (58%) were above 35 years old. More than three fourth of the women (83.4%) had no formal education and only 22% of the women aged 15–49 were in the rich wealth quintile.
Based on Table
2, one in every ten women of 15 to 49 years old, in Amhara region, (10%) made one or extra antenatal visits during the route of pregnancy. Of these women 42% were using modern contraceptive methods. Besides, the most popular contemporary contraceptive method utilized by 30% of the women, 15 to 49 years old, was injectables.
As Table
3 shows, some 218 (8.5%) women had stillbirth outcomes. Only 40 (1.6%) women had signs of pregnancy complications. Of which abdominal pain experienced the majority, and considerable number of women, 160 (41%) were taking iron. On top of these pregnancy complications, about 162 (66.9%) women were diagnosis hypertensive as their systolic and diastolic blood stress with greater than 120 mmHg and 80 mmHg based on American Heart Association (AHA) classification.
Multivariate analysis for predicting stillbirth outcomes
One problem of single covariate approach is that it ignores the opportunity that a collection of variables, each of which is weakly associated with the final results, and this can turn out to be a vital predictor of the outcome whilst taken collectively. It is miles consequently essential to reduce the possibility of excluding variables on the bivariable analysis level. It is for this reason that a bi-variable test
p-value of 0.25 or much less used for selection of variables for the multi covariate analysis from single covariate findings [
10]. Totally based on such lists like residence, age, educational level, wealth index, antenatal care attendance, number of antenatal care visits, modern contraceptive used, kind of contraceptive used, place of delivery and preceding birth interval in months were selected for forward likelihood method.
As Table
4 indicates, after adjusting other covariates, women whose age below 24 years was about 71% less likely to have stillbirth outcomes than those whose age was above 35 years old (AOR: 0.288, 95% CI 0.126–0.656). Similarly, women aged between 25 and 34 years was about 78% less likely to have had stillbirth outcomes than those whose age was above 35 years old (AOR: 0.221, 95% CI 0.155–0.314). The women attended primary and above education was about 50% less likely to have had stillbirth outcomes than those of having no education (AOR: 0.505, 95% CI 0.311–0.820). In addition, women having wealth index rich and the middle was about 70% (AOR: 0.302, 95% CI 0.204–0.447) and 71% (AOR: 0.290, 95% CI 0.213–0.396) less likely to have had stillbirth outcomes than those of having poor wealth index.
Table 4
Logistic regression analysis of factors associated with stillbirth in Amhara Region, Ethiopia
Residence |
Urban | 153 | 11 | 0.000 | 0.072 (0.039–0.133) | | |
Rural | 2184 | 207 | | 1 | | |
Age | | | 0.000 | | 0.000 | |
< 24 | 159 | 19 | 0.000 | 0.119 (0.074–0.192) | 0.003 | 0.288 (0.126–0.656) |
25–34 | 839 | 64 | 0.000 | 0.076 (0.059–0.098) | 0.000 | 0.221 (0.155–0.314) |
35+ | 1339 | 135 | | 1 | | 1 |
Educational Level |
No education | 1950 | 181 | | 1 | | 1 |
Primary & Above | 387 | 37 | | 0.096 (0.068–0.134) | 0.006 | 0.505(0.311–0.820) |
Wealth Index | | | 0.000 | | 0.000 | |
Poor | 1155 | 99 | | 1 | | 1 |
Middle | 682 | 70 | 0.000 | 0.103 (0.080–0.131) | 0.000 | 0.290 (0.213–0.396) |
Rich | 500 | 49 | 0.000 | 0.098 (0.073–0.131) | 0.000 | 0.302 (0.204–0.447) |
Did you attend antenatal care? |
No | 2101 | 211 | | 1 | | |
Yes | 236 | 7 | 0.000 | 0.030 (0.014–0.063) | | |
Number of Antenatal care Visits |
No Visit | 138 | 9 | | 1 | | |
1+ | 231 | 7 | 0.000 | 0.030 (0.014–0.064) | | |
Modern Contraceptive Used Prior to Current Pregnancy |
No | 1483 | 138 | | 1 | | |
Yes | 854 | 80 | 0.000 | 0.094 (0.074–0.118) | | |
Type of Contraceptive used | 0.000 | | | |
Not Using | 1458 | 136 | | 1 | | |
Injections | 687 | 71 | 0.000 | 0.103 (0.081–0.132 | | |
Others | 192 | 11 | 0.000 | 0.057 (0.031–0.105) | | |
Place of Delivery |
Home | 443 | 22 | | 1 | | |
Health Center | 52 | 6 | 0.000 | 0.115 (0.050–0.269) | | |
Preceding Birth Interval in Months | | | 0.000 | |
< 24 | 793 | 104 | | | | 1 |
25–36 | 520 | 20 | 0.000 | 0.038 (0.025–0.060) | 0.001 | 0.093 (0.059–0.148 |
36+ | 489 | 23 | 0.000 | 0.047 (0.031–0.071) | 0.0001 | 0.109 (.071–0.168 |
The preceding birth interval was the strongest predictor of stillbirth outcomes. Women having preceding birth interval above 36 months were about 89% less likely to end up stillbirth outcomes as compared to women having preceding birth interval below 24 months (AOR: 0.109, 95% CI 0.071–8.0.168). Likewise, women having a preceding birth interval between 25 and 36 months were about 91% less likely to end up stillbirth outcomes as compared to women having preceding birth interval below 24 months (AOR: 0.093, 95% CI 0.059–0.148).
Discussion
In this study, prevalence and related factors of stillbirth results at Amhara regional state, Ethiopia was assessed and the prevalence rate of stillbirth was 85 per 1000 total births. This prevalence is higher than a study conducted in four low and middle-income countries and this showed a stillbirth rate of 30 per thousand deliveries [
11]. This number is also higher than the previous reports of the world health statistics 2013 stated as a stillbirth rate of 26 per 1000 in Ethiopia, 34 per 1000 in Djibouti and 30 per 1000 births in Somalia [
5]. Moreover, as the 2005 EDHS Survey [
6] data showed stillbirth rate was 18 per 1000 births [
6]. This is because the consecutive Ethiopian DHS was underreported because of omission and missed reporting [
6,
12‐
14]. Underreporting occurs for some of the motives, such as inclusive of the exercise of keeping apart women and their newborns within the early postnatal length, and reputation of new child loss of life as regular, and a perception that the new child is not someone for a detailed time frame [
6]. Besides, additionally almost all stillbirths were underreported and the underreporting of stillbirth was disregarded in the international health schedule [
7,
12,
15,
16]. These things could happen because now these days stillbirths are often now not registered systematically in lots of low-income countries which need p in underestimation of stillbirths in these nations, wherein 98% of all stillbirths occur as well as reliable registrations exist only in countries with a minor number of deaths [
7]. In addition, stillbirths in Ethiopia in general and in Amhara region in particular are attributed to supernatural powers which do not need to be talked about then they are buried within the house or inside the outdoor [
12]. This prevalence is even higher than what Gondar University hospital reported as 71 per 1000 total births [
17]. Such may be because giving birth at the hospital had better facilities than those who did difference home. In this study, the majority of the women (88.4%) gave birth at home.
A woman in a rural home will meet several challenges if an acute obstetric emergency occurs. Limited finances and no available transportation were two major obstacles as poor women had given higher stillbirth outcomes than that of rich women [
17,
18]. The Ethiopian government has been trying to provide community-based emergency transportation (ambulance) though the existing road next works do not create access to rural women in Amhara region, Ethiopia. Among the socioeconomic status wealth index was also associated with stillbirth outcomes in that women who had higher wealth index experienced fewer stillbirth outcomes compared to those who had low wealth index. This finding is consistent with Ha et al. study which reported that as women in the poorest two quintiles they have had more threat of stillbirth as compared to the richest women [
19].
Moreover, in this study showed that older maternal age is associated with higher stillbirth rates. Compared with women of 35 years old, there was about 71% increment of the risk in stillbirth for women less than 24 years old [
20], and about 78% increment of risk in stillbirth for women 25 to 34 years old. The result of this study also similar to Audu et al. study in Nigeria [
21] which showed women less than 35 years old, the stillbirth rate is increased two-fold for women with 35 to 39 years old, and added three to four-fold for women aged 40 or above. Consequently, older women stillbirth threat rises more rapidly as gestational age increases due to some age-associated threat had higher rates of maternal complications.
In bivariable analysis, women who had more than one ANC followed up during the current pregnancy were about 97% less likely to have a stillbirth than women did now not have ANC follow up.
This finding could support the previous studies that used is in keeping with preceding studies at Gondar hospital using multivariate analysis at Gondar Hospital [
17]. For example, Akilew et al. stated that regular ANC follow up could help a pregnant woman seek early treatment for her potential pregnancy associated troubles and have access to information related to nutrition and hazard signs and symptoms of being pregnant. On the other hand, the researchers noted that women who did not have longer ANC follow up may not be benefited from basic ANC packages.
This study farther showed women who had above 36 months preceding birth interval were about 89% less likely to have had stillbirth outcomes than those of women their preceding birth interval was below 24 months. Such result is in congruent with the findings of a study by Elizabeth et al. as they suggested that short inter-being pregnant intervals are a few of the maximum common threat factors for stillbirths in developing nations [
22]. In addition, Assefa et al. stated that the threat of pregnancy loss changed into notably reduced for women who had a pregnancy interval of two or extra years in comparison with women who had a being pregnant interval of below two years [
23].
Conclusions
Authors concluded that stillbirth is one of the public health problems in Amhara Region, Ethiopia. Among different factors considered in this study, age, age at first birth, wealth index, birth order number and preceding birth interval in months were significantly associated factors for stillbirth outcomes. Moreover, older maternal age and short preceding birth interval were associated factors for stillbirth.
Hence, further awareness of early birth and wider birth interval are important recommendations. Authors also recommend further enhancements of maternal care for aged women as well as during early birth order number.