Background
Methods
Study design
Study population
Statistical analysis
Results
Maternal characteristics of those who had live and stillborn infants
Maternal characteristics | Live-birth (n = 650) | Stillbirth (n = 49) | Total (n = 699) |
p value |
---|---|---|---|---|
Data collected from medical records | ||||
Maternal Age (years) | 647 (100) | 49 (100) | 696 (100) | |
< 20 | 77 (11.9) | 7 (14.3) | 84 (12.1) | 0.294 |
20–35 | 430 (69.6) | 29 (59.2) | 479 (68.8) | |
> 35 | 143 (18.5) | 13 (26.5) | 133 (19.1) | |
Mean ± SD | 27.94 ± 7.00 | 29.65 ± 7.6 | 28.06 ± 7.05 | 0.101 |
Range | 14–50 | 14–44 | 14–50 | |
Gravidity | 648 (100) | 49 (100) | 697 (100) | |
1 | 311 (48.0) | 19 (38.8) | 330 (47.3) | 0.460 |
2–3 | 246 (38.0) | 14 (44.9) | 268 (38.5) | |
4+ | 91 (14) | 8 (16.3) | 99 (14.2) | |
Insurance | 642 (100) | 49 (100) | 691 (100) | |
Insurance for the poor | 350 (54.5) | 25 (51.0) | 375 (54.3) | 0.452 |
Other insurance | 37 (5.8) | 5 (10.2) | 42 (6.1) | |
Out of pocket | 255 (39.7) | 19 (38.8) | 274 (39.7) | |
Residence | 650 (100) | 49 (100) | 699 (100) | |
Urban | 139 (21.4) | 10 (20.4) | 149 (21.3) | 0.872 |
Rural | 511 (78.6) | 39 (79.6) | 550 (78.7) | |
Referral (info from case notes) | 650 (100) | 49 (100) | 699 (100) | |
Referred from other health provider | 483 (74.3) | 30 (61.2) | 513 (73.4) |
0.046
|
Self referred | 167 (25.7) | 19 (38.8) | 186 (26.6) | |
Time of Admission | 646 (100) | 47 (100) | 693 (100) | |
Weekdays (07.01–14.00) | 273 (42.3) | 21 (44.7) | 294 (42.4) | 0.957 |
(14.01–21.00) | 156 (24.1) | 12 (25.5) | 168 (24.2) | |
(21.01–07.00) | 134 (20.7) | 9 (19.1) | 143 (20.6) | |
Weekend | 83 (12.9) | 5 (10.6) | 88 (12.7) | |
Time of Delivery | 535 (100) | 45 (100) | 580 (100) | |
Weekdays (07.01–14.00) | 239 (44.7) | 18 (40) | 257 (44.3) | 0.202 |
(14.01–21.00) | 102 (19.1) | 14 (31.1) | 116 (20) | |
(21.01–07.00) | 116 (21.7) | 6 (13.3) | 122 (21) | |
Weekends | 78 (14.6) | 7 (15.6) | 85 (14.7) | |
Maternal Diagnosisa
| 650 (100) | 49 (100) | 699 (100) | |
Normal (or minor complications) | 75 (11.5) | 15 (30.6) | 90 (12.9) |
<0.001
|
Antepartum hemorrhage | 26 (4.0) | 4 (8.2) | 30 (4.3) | 0.166 |
Postpartum hemorrhage | 31 (4.8) | 7 (14.3) | 38 (5.4) |
0.005
|
Severe preeclampsia/eclampsia | 72 (11.1) | 7 (14.3) | 79 (11.3) | 0.494 |
Maternal hypertension not associated with preeclampsia/eclampsia | 59 (9.1) | 2 (4.1) | 61 (8.7) | 0.301 |
PROM | 181 (27.8) | 4 (8.2) | 185 (26.5) |
0.003
|
Dystocia | 175 (26.9) | 6 (12.2) | 181 (25.9) |
0.024
|
Malpresentation | 68 (10.5) | 15 (30.6) | 83 (11.9) |
<0.001
|
Obstetric Infection | 9 (1.4) | 4 (8.2) | 13 (1.9) |
0.001
|
Mode of Delivery | 650 (100) | 49 (100) | 699 (100) | |
Spontaneous | 347 (53.4) | 40 (81.6) | 387 (55.4) |
0.001
|
Assisted vaginal | 22 (3.4) | 0 (0) | 22 (3.1) | |
Cesarean | 281 (43.2) | 9 (18.4) | 290 (41.5) | |
Severity of illness | 650 (100) | 49 (100) | 699 (100) | |
No complications | 75 (11.5) | 15 (30.6) | 90 (12.9) |
<0.001
|
Mild-severe complications | 521 (80.2) | 25 (51.0) | 546 (78.1) | |
Near-miss or death | 54 (8.3) | 9 (18.4) | 63 (9) | |
Near-miss by time | 650 (100) | 49 (100) | 699 (100) | |
Non Near-miss | 596 (91.7) | 42 (85.7) | 638 (91.3) |
0.047
|
Near-miss at admission | 19 (2.9) | 5 (10.2) | 24 (3.4) | |
Near-miss after admission | 25 (3.8) | 2 (4.1) | 27 (3.9) | |
Near-miss time unclear | 10 (1.5) | 0 (0) | 10 (1.4) |
Maternal characteristics | Live birtha
(n = 406) | Stillbirtha (n = 28) | Total (n = 434) |
p value |
---|---|---|---|---|
Women’s education (attended) | 406 (100) | 28 (100) | 434 (100) | |
No schooling | 6 (1.5) | 0 (0) | 6 (1.4) | 0.548 |
Elementary | 201 (49.5) | 10 (35.7) | 211 (48.6) | |
Junior high | 116 (28.6) | 11 (39.3) | 127 (29.3) | |
Senior high | 64 (15.8) | 6 (21.4) | 70 (16.1) | |
Academy/University | 19 (4.7) | 1 (3.6) | 20 (4.6) | |
Husbands’ education (attended) | 392 (100) | 27 (100) | 419 (100) | |
No schooling | 7 (1.8) | 0 (0) | 7 (1.7) | 0.652 |
Elementary | 182 (46.4) | 14 (51.9) | 196 (46.8) | |
Junior high | 97 (24.7) | 6 (22.2) | 103 (24.6) | |
Senior high | 84 (21.4) | 7 (25.9) | 91 (21.7) | |
Academy/University | 22 (5.6) | 0 (0) | 22 (5.3) | |
Woman’s occupation | 406 (100) | 28 (100) | 434 (100) | |
Not employed | 276 (68.0) | 16 (57.1) | 292 (67.3) | 0.237 |
Employed | 130 (32.0) | 12 (42.9) | 142 (32.7) | |
SES | 406 (100) | 28 (100) | 434 (100) | |
Quintile 1 (the poorest) | 49 (12.1) | 3 (10.7) | 52 (12) | 0.925 |
Quintile 2 | 105 (25.9) | 8 (28.6) | 113 (26) | |
Quintile 3 | 91 (22.4) | 6 (21.4) | 97 (22.4) | |
Quintile 4 | 95 (23.4) | 5 (17.9) | 100 (23) | |
Quintile 5 (the richest) | 66 (16.3) | 6 (21.4) | 72 (16.6) | |
Referral characteristics | 406 (100) | 28 (100) | 434 (100) | |
Referred directly to hospital | 255 (62.8) | 18 (64.3) | 273 (62.9) | 0.774 |
Multiple referrals before admission | 120 (29.6) | 7 (25.0) | 127 (29.3) | |
Self referred | 31 (7.6) | 3 (10.7) | 34 (7.8) | |
Total time travel estimated to reach nearest hospital (hour) | 375 (100) | 22 (100) | 397 (100) | |
Mean ± SD | 0.63 ± 0.54 | 0.69 ± 0.70 | 0.6 ± 0.6 | 0.590 |
Range | 0.02 – 3.50 | 0.08 – 3.00 | 0.02–3.50 | |
Total time estimated (estimated) by category to nearest hospital | 375 (100) | 22 (100) | 397 (100) | |
< 0.5 h | 159 (42.4) | 10 (45.5) | 169 (42.6) | 0.450 |
0.5- < 1 h | 112 (29.9) | 5 (22.7) | 117 (29.5) | |
1- < 1.5 h | 66 (17.6) | 3 (13.6) | 69 (17.4) | |
1.5- < 2 h | 18 (4.8) | 3 (13.6) | 21 (5.3) | |
> =2 h | 20 (5.3) | 1 (4.5) | 21 (5.3) | |
Total time since left home until arrived at study hospital (hour) | 329 (100) | 22 (100) | 351 (100) | |
Mean ± SD | 12.3 ± 20.2 | 6.2 ± 10.4 | 11.9 ± 19.8 | 0.162 |
Range | 0.28 – 159.8 | 0.7 – 48.0 | 0.28 – 159.8 | |
Total time traveled to reach study hospital | 329 (100) | 22 (100) | 351 (100) | |
< 0.5 h | 8 (2.4) | 0 (0) | 8 (2.3) | 0.254 |
0.5- < 1 h | 13 (4.0) | 3 (13.6) | 16 (4.6) | |
1- < 1.5 h | 34 (10.3) | 3 (13.6) | 37 (10.5) | |
1.5- < 2 h | 28 (8.5) | 2 (9.1) | 22 (6.3) | |
> =2 h | 246 (74.8) | 14 (63.6) | 268 (76.4) | |
Type of transportation used to reach study hospital (actual) | 367 (100) | 26 (100) | 393 (100) | |
By foot/ Becak/bicycle | 11 (3.0) | 0 (0) | 11 (2.8) | 0.174 |
Motorbike/ojek
| 55 (15.0) | 8 (30.8) | 63 (16) | |
Ambulance | 128 (34.9) | 5 (19.2) | 133 (33.8) | |
Public transportation | 121 (33.0) | 9 (34.6) | 130 (33.1) | |
Private car (non ambulance) | 52 (14.2) | 4 (15.4) | 56 (14.2) | |
Distance (km) to reach nearest hospital (estimated) | 185 (100) | 14 (100) | 199 (100) | |
Mean ± SD | 12.9 ± 15.7 | 17.2 ± 19.8 | 13.2 ± 16 | 0.334 |
Range | 0.05–80 | 0.05–60 | 0.05–80 | |
Distance to reach nearest hospital (estimated) | 185 (100) | 14 (100) | 199 (100) | |
< 5 km | 64 (34.6) | 4 (28.6) | 68 (34.2) | 0.773 |
5–9.9 km | 59 (31.9) | 4 (28.6) | 63 (31.7) | |
10+ km | 62 (33.5) | 6 (42.9) | 68 (34.2) | |
Distance (km) traveled to reach study hospital (actual) | 131 (100) | 10 (100) | 141 (100) | |
Mean ± SD | 20.0 ± 18.4 | 32.5 ± 23.3 | 20.8 ± 19.0 | 0.056 |
Range | 1 - 85 | 11 – 83 | 1 - 85 | |
Distance to reach study hospital (actual) – categorized | 131 (100) | 10 (100) | 141 (100) | |
< 5 km | 34 (26.0) | 1 (10.0) | 35 (24.8) | 0.116 |
5–9.9 km | 22 (16.8) | 0 (0) | 22 (15.6) | |
10+ km | 75 (57.3) | 9 (90.0) | 84 (59.6) | |
Reported barrier to referral | 406 (100) | 28 (100) | 434 (100) | |
Personal barrier | 26 (6.4) | 0 (0) | 26 (6) | 0.167 |
Transportation barrier | 54 (13.3) | 3 (10.7) | 57 (13.1) | 0.695 |
Geographic barrier | 71 (17.5) | 10 (35.7) | 81 (18.7) |
0.017
|
Fund barrier | 65 (16) | 6 (21.4) | 71 (16.4) | 0.453 |
Administrative barrier | 38 (9.4) | 5 (17.9) | 43 (9.9) | 0.145 |
Prenatal Care | 406 (100) | 28 (100) | 434 (100) | |
Yes | 395 (97.3) | 26 (92.9) | 421 (97) | 0.183 |
Number of visits 4+ | 325 (83.8) | 17 (63.0) | 342 (82.4) |
0.006
|
Initiated 1st trimester | 319 (83.5) | 25 (89.3) | 344 (83.9) | 0.612 |
Initiated 2nd trimester | 54 (14.1) | 3 (10.7) | 57 (13.9) | |
Initiated 3rd trimester | 9 (2.4) | 0 (0) | 9 (2.2) |
Maternal risk factors associated with stillbirth
Neonatal characteristics
Neonatal characteristics |
n = 650 (%) |
---|---|
Infant Sex | |
Male | 358 (55.1) |
Female | 292 (44.9) |
Birthweight (kg) | |
< 1000 | 9 (1.4) |
1000–1499 | 13 (2) |
1500–1999 | 19 (2.9) |
2000–2499 | 58 (8.9) |
2500–2999 | 200 (30.8) |
3000–3999 | 330 (50.8) |
≥ 4000 | 16 (2.5) |
Not recorded | 5 (0.8) |
Apgar Score at 5 min | |
< 5 | 82 (12.6) |
≥ 5 | 565 (86.9) |
Not recorded | 3 (0.5) |
Breastfed | |
Yes | 317 (48.8) |
Not recorded | 107 (16.5) |
Neonatal Diagnosesa
| |
Normal | 242 (39.3) |
LBW | 99 (15.2) |
VLBW | 22 (3.4) |
Respiratory distress | 38 (5.8) |
Asphyxia | 103 (15.8) |
Sepsisb
| 10 (1.5) |
Meconium stained amniotic fluid | 33 (5.1) |
At risk for sepsisb
| 63 (9.7) |
Post-Caesarean Section | 43 (6.6) |
Neonatal death | 34 (5.2) |
No diagnosis recorded in medical record | 38 (5.8) |
Maternal risk factors associated with Low birthweight, very low birthweight, neonatal asphyxia, stillbirth, perinatal death and neonatal death
Maternal risk factor | Bivariate Analysis Odds Ratios [95% CI] |
p-value | Reduced Logistic Model Adjusted Odds Ratios [95% CI] |
p-value |
---|---|---|---|---|
Low Birthweight (n = 357) | ||||
Young maternal age (<20 years) |
1.83 [1.03, 3.25]
|
0.04
| ||
Primagravida |
1.78 [1.52, 2.74]
|
0.01
| ||
Rural residence | 1.81 [0.99, 3.29] | 0.05 | ||
Referred from another facility |
0.47 [0.24, 1.90]
|
0.02
| 0.28 [0.11, 0.69]
| 0.01
|
Antepartum hemorrhage |
2.57 [1.09, 6.08]
|
0.03
| ||
Eclampsia | 1.68 [0.92, 3.07] | 0.09 | ||
Near miss |
2.08 [1.08, 3.98]
|
0.03
| ||
Time to reach nearest hospital >1 h | 1.88 [0.88, 4.02] | 0.10 | ||
Prenatal care visits (<4 visits) |
2.66 [1.06, 6.70]
|
0.04
| ||
Very Low Birthweight (n = 388) | ||||
Young maternal age (<20 years) |
3.72 [1.47, 9.44]
|
<0.01
|
6.39 [1.82, 22.35]
|
<0.01
|
Referral from another facility |
0.22 [0.08, 0.58]
|
<0.01
|
0.18 [0.04, 0.75]
|
0.02
|
Mother presented with complication |
0.33 [0.13, 0.87]
|
0.03
| ||
Antepartum hemorrhage |
4.15 [1.15, 15.04]
|
0.03
| ||
Prenatal care visits (<4 visits) | 3.27 [0.67, 15.98] | 0.14 | ||
Asphyxia (n = 357) | ||||
Primagravida | 1.42 [0.93, 2.17] | 0.11 | ||
Insurance for the poor | 1.54 [0.99, 2.34] | 0.05 | ||
Rural residence |
4.36 [1.98, 9.63]
|
<0.001
|
5.37 [1.98, 18.16]
|
<0.01
|
Near miss after admission | 2.14 [0.88, 5.27] | 0.10 | ||
Malpresentation |
3.47 [2.00, 6.03]
|
<0.001
|
4.65 [2.23, 9.70]
|
<0.001
|
Low education | 2.10 [0.96, 4.58] | 0.06 | ||
Multiple referrals | 0.57 [0.30, 1.08] | 0.09 | ||
Prenatal care visits (<4 visits) | 1.98 [0.79, 4.90] | 0.14 | ||
Stillbirth (n = 699) | ||||
Referral from another facility |
0.40 [0.18, 0.86]
|
0.019
|
0.41 (0.18, 0.95]
|
0.37
|
Postpartum hemorrhage |
3.33 [1.38, 8.01]
|
0.007
| ||
PROM |
0.23 [0.08, 0.65]
|
0.006
|
0.27 [0.09, 0.76]
|
0.014
|
Malpresentation |
3.78 [1.96, 7.29]
|
<0.001
|
4.27 [2.11, 8.62]
|
<0.001
|
Dystocia |
0.38 [0.16, 0.91]
|
0.029
| ||
Caesarean Section |
0.30 [0.14, 0.62]
|
0.001
|
0.28 [0.13, 0.60]
|
0.001
|
Near miss on admission |
3.77 [1.35, 10.59]
|
0.012
| ||
Near miss at any time |
2.48 [1.14, 5.39]
|
0.021
|
3.54 [1.53, 8.21]
|
0.003
|
Neonatal deaths (n = 375) | ||||
Young maternal age (<20 years) |
2.90 [1.30, 6.48]
|
<0.01
|
4.10 [1.29, 13.02]
|
0.02
|
Advanced maternal age | 0.26 [0.06, 1.12] | 0.07 | ||
Primagravida | 2.06 [1.00, 4.24] | 0.05 | ||
Referral from another facility |
0.31 [0.13, 0.75]
|
0.01
|
0.20 [0.05, 0.81]
|
0.02
|
Antepartum hemorrhage | 2.5 [0.71, 8.76] | 0.15 | ||
Postpartum hemorrhage | 2.9 [0.96, 8.85] | 0.06 |
4.11 [1.03, 16.39]
|
0.05
|
Near miss on admission |
2.58 [1.07, 6.22]
|
0.03
|
11.67 [2.08, 65.65]
|
<0.01
|
Caesarean Section | 0.53 [0.25, 1.13] | 0.10 | ||
Near miss at any time |
5.42 [2.44, 12.04]
|
<0.001
|
7.5 [2.24, 25.08]
|
<0.01
|
Belonging to the two poorest income quintiles | 0.36 [0.10, 1.30] | 0.12 | ||
Time to reach nearest hospital >1 h | 0.76 [0.17, 1.31] | 0.15 | ||
Perinatal deaths (n = 348) | ||||
Young maternal age 9 < 20 years) | 1.99 [1.09, 3.61] | 0.02 | ||
Referral from another facility |
0.33 [0.18, 0.61]
|
<0.001
| ||
Time of delivery (at night) | 0.68 [0.41, 1.11] | 0.12 | ||
Antepartum hemorrhage | 2.19 [0.92, 5.15] | 0.08 | ||
Postpartum hemorrhage |
2.70 [1.32, 5.52]
|
<0.01
|
3.96 [1.41, 11.15]
|
<0.01
|
Malpresentation |
2.59 [1.47, 4.57]
|
<0.01
|
3.89 [1.42, 10.64]
|
<0.01
|
Near miss on admission |
5.27 [2.42, 11.47]
|
<0.001
|
13.08 [3.77, 45.37]
| <0.001 |
Near miss at any time |
3.24 [1.81, 5.77]
|
<0.001
|
6.00 [2.32, 15.50]
|
<0.001
|
Mother presented with complication |
0.41 [0.23, 0.71]
|
<0.01
|
0.30 [0.11, 0.81]
|
0.02
|
Caesarean Section |
0.37 [0.22, 0.64]
|
<0.001
| ||
Prenatal care visits (<4 visits) |
5.17 [2.34, 11.39]
|
<0.001
|
6.70 [2.71, 16.62]
|
<0.001
|