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Background and aims Stillbirth rate is an indicator reflecting quality of maternal healthcare services available to a pregnant woman in a country. At the community and individual level, it continues to be a public health tragedy. This paper presents the stillbirth rate, its causes and characteristics of women who experienced stillbirth from five years data of hospital-based stillbirth surveillance system. We also attempted to study the association between number of antenatal check-ups and causes of stillbirths, period of gestation and maternal parameters like presence of anaemia at the time of delivery. Methodology A multisite hospital-based sentinel surveillance system for estimating the stillbirth rate and its causes was established across seven tertiary care government hospitals of Delhi, India in 2015. A standardized stillbirth form was used to record information, and data was collected using an online portal from all hospitals. The data from 2016 to 2020 was analysed for calculating the stillbirth rate, its causes and maternal characteristics using STATA version 17. Results Of the 12,569 stillbirths recorded among 416,677 deliveries, the still birth rate over the time period 2016–2020 was 29.3 per 1000 births. Nearly 50% women who experienced stillbirths did not receive any antenatal care. Antepartum stillbirths were more common (75.7%), the remaining were the intrapartum stillbirths (24.3%). Among antepartum causes, the most prevalent maternal cause was preterm labour (25.7%) followed by placental abruption/placenta previa/hemorrhage in 15.2%. Among foetal causes, majority of the still births were due to fetal growth restriction (31.2%) followed by congenital malformations (7%). Uterine rupture and eclampsia were reported as major intrapartum causes leading to still births in 11% and 8.3% cases, respectively. Conclusions The stillbirth rate of 29.3 per 1,000 births from hospital data underscores the need for community-based surveillance. Nearly half of pregnant women lacked antenatal care, and 75% of stillbirths were antepartum, stressing the need to strengthen antenatal care- both coverage and quality. Routine symphysio-fundal height measurements, mandatory third-trimester ultrasounds, and partograph use may help reduce intrapartum stillbirths.

Background 2.7 million babies were stillborn in 2015 worldwide; behind these statistics lie the experiences of bereaved parents. The first Lancet series on stillbirth in 2011 described stillbirth as one of the “most shamefully neglected” areas of public health, recommended improving interaction between families and frontline caregivers and made a plea for increased investment in relevant research. Methods A systematic review of qualitative, quantitative and mixed-method studies researching parents and healthcare professionals experiences of care after stillbirth in high-income westernised countries (Europe, North America, Australia and South Africa) was conducted. The review was designed to inform research, training and improve care for parents who experience stillbirth. Results Four thousand four hundred eighty eight abstracts were identified; 52 studies were eligible for inclusion. Synthesis and quantitative aggregation (meta-summary) was used to extract findings and calculate frequency effect sizes (FES%) for each theme (shown in italics), a measure of the prevalence of that finding in the included studies. Researchers’ areas of interest may influence reporting of findings in the literature and result in higher FES sizes, such as; support memory making (53 %) and fathers have different needs (18 %). Other parental findings were more unexpected; Parents want increased public awareness (20 %) and for stillbirth care to be prioritised (5 %). Parental findings highlighted lessons for staff; prepare parents for vaginal birth (23 %), discuss concerns (13 %), give options & time (20 %), privacy not abandonment (30 %), tailored post-mortem discussions (20 %) and post-natal information (30 %). Parental and staff findings were often related; behaviours and actions of staff have a memorable impact on parents (53 %) whilst staff described emotional, knowledge and system-based barriers to providing effective care (100 %). Parents reported distress being caused by midwives hiding behind ‘doing’ and ritualising guidelines whilst staff described distancing themselves from parents and focusing on tasks as coping strategies. Parents and staff both identified the need for improved training (parents 25 % & staff 57 %); continuity of care (parents 15 % & staff 36 %); supportive systems & structures (parents 50 %); and c lear care pathways (parents 5 %). Conclusions Parents’ and healthcare workers’ experiences of stillbirth can inform training, improve the provision of care and highlight areas for future research.

Background Despite improvements in maternity healthcare services over the last few decades, more than 2.7 million babies worldwide are stillborn each year. The global health agenda is silent about stillbirth, perhaps, in part, because its wider impact has not been systematically analysed or understood before now across the world. Our study aimed to systematically review, evaluate and summarise the current evidence regarding the psychosocial impact of stillbirth to parents and their families, with the aim of improving guidance in bereavement care worldwide. Methods Systematic review and meta-summary (quantitative aggregation of qualitative findings) of quantitative, qualitative, and mixed-methods studies. All languages and countries were included. Results Two thousand, six hundred and nineteen abstracts were identified; 144 studies were included. Frequency effect sizes (FES %) were calculated for each theme, as a measure of their prevalence in the literature. Themes ranged from negative psychological symptoms post bereavement (77 · 1) and in subsequent pregnancies (27 · 1), to disenfranchised grief (31 · 2), and incongruent grief (28 · 5), There was also impact on siblings (23 · 6) and on the wider family (2 · 8). They included mixed-feelings about decisions made when the baby died (12 · 5), avoidance of memories (13 · 2), anxiety over other children (7 · 6), chronic pain and fatigue (6 · 9), and a different approach to the use of healthcare services (6 · 9). Some themes were particularly prominent in studies of fathers; grief suppression (avoidance)(18 · 1), employment difficulties, financial debt (5 · 6), and increased substance use (4 · 2). Others found in studies specific to mothers included altered body image (3 · 5) and impact on quality of life (2 · 1). Counter-intuitively, Some themes had mixed connotations. These included parental pride in the baby (5 · 6), motivation for engagement in healthcare improvement (4 · 2) and changed approaches to life and death, self-esteem, and own identity (25 · 7). In studies from low/middle income countries, stigmatisation (13 · 2) and pressure to prioritise or delay conception (9) were especially prevalent. Conclusion Experiencing the birth of a stillborn child is a life-changing event. The focus of the consequences may vary with parent gender and country. Stillbirth can have devastating psychological, physical and social costs, with ongoing effects on interpersonal relationships and subsequently born children. However, parents who experience the tragedy of stillbirth can develop resilience and new life-skills and capacities. Future research should focus on developing interventions that may reduce the psychosocial cost of stillbirth.

Background Nearly half of all stillbirths occur in sub-Saharan Africa and accurate registration could inform reduction efforts. We explored the beliefs and practices surrounding stillbirths in Eastern Uganda, revealing cultural factors that could influence the accurate counting of stillbirths. Methods We conducted a qualitative study among women with a history of stillbirths, and men, women and community leaders with an experience of childbirth in Eastern Uganda. The study also included healthcare workers from three health facilities. We conducted 30 in-depth interviews and six focus group discussions to explore the beliefs and practices about stillbirths. All discussions and interviews were audio recorded and transcribed into English. Thematic analysis was done using NVivo R1 (2020) software for coding. Results We enrolled a total of 74 participants: 44 in six focus group discussions and 30 in in-depth interviews. Four themes emerged: first, the community believed that stillborn babies can be used for witchcraft or as a source of curses therefore stillbirths were hidden from the public. Second, women were useful in marriage only when they bore live children and were despised when they had a stillbirth leading to discord in marriage and stigma. Third, stillborn babies were not considered human and therefore, the baby was not named or buried in a coffin. Fourth, the spirit of the stillborn baby was considered harmful to the next siblings and their parents sought the services of traditional healers and witch doctors to protect these siblings. Conclusion The immediate tragedy of a stillbirth has long-term personal and societal effects on the mother, resulting in stigma, marital breakup and isolation. The secrecy about stillbirths may also contribute to underreporting of stillbirths. Efforts to improve documentation of stillbirths and support for families who have had stillbirths need to incorporate culturally sensitive interventions.

Background Each year 182,000 babies are stillborn in Nigeria, representing nearly 10% of the annual global stillbirth burden. Imo state in south-eastern Nigeria has one of the highest levels of maternal health service access in Nigeria, yet this has not translated into good pregnancy outcomes. Many stillbirth prevention initiatives in Nigeria focus on maternal health education but empirical evidence suggests that sociocultural factors impact healthcare choices and outcomes. This study aims to explore women’s and health workers’ perspectives of the sociocultural barriers to following medical advice during pregnancy and childbirth, and specifically how these barriers may contribute to an increased risk of stillbirth. This study is part of a broader community-based stillbirth prevention mixed-methods research in Imo State, Nigeria. Methods A qualitative descriptive study was conducted using in-depth interviews and focus group discussions. 38 participants were purposively recruited; 20 women and 18 health workers. Audio recordings were transcribed, translated and analysed using inductive thematic analysis. Results Four themes were identified: (1) trust, where scepticism about health worker motives or competence and trust in community informal networks were highlighted (2) power dynamics within families, with husbands and older female relatives influencing health decisions; (3) personal and community beliefs that undermine confidence in medical interventions, including a pervasive stigma associated with caesarean section; and (4) grassroots proposals for solutions, emphasising the importance of a whole-community approach to maternal health education, mobilising peer voices, engaging traditional leaders and training of traditional birth attendants. Conclusion This study provides insights into the sociocultural barriers to following medical advice during pregnancy in Nigeria, which include a lack of trust in health professionals, power dynamics within a woman’s family, and entrenched cultural and religious beliefs that oppose medical intervention. Women’s decisions about pregnancy and childbirth are heavily influenced by family and cultural norms. Culturally sensitive, community-wide interventions which aim to rebuild trust in the health system, involve women as decision-makers in antenatal care, and engage religious and traditional leaders would be beneficial for improving outcomes.

Background The causes of some stillbirths are unclear, and additional work must be done to investigate the risk factors for stillbirths. Objective To apply the International Classification of Disease-10 (ICD-10) for antepartum stillbirth at a referral center in eastern China. Methods Antepartum stillbirths were grouped according to the cause of death according to the International Classification of Disease-10 (ICD-10) criteria. The main maternal condition at the time of antepartum stillbirth was assigned to each patient. Results Antepartum stillbirths were mostly classified as fetal deaths of unspecified cause, antepartum hypoxia. Although more than half of the mothers were without an identified condition at the time of the antepartum stillbirth, where there was a maternal condition associated with perinatal death, maternal medical and surgical conditions and maternal complications during pregnancy were most common. Of all the stillbirths, 51.2% occurred between 28 and 37 weeks of gestation, the main causes of stillbirth at different gestational ages also differed. Autopsy and chromosomal microarray analysis (CMA) were recommended in all stillbirths, but only 3.6% received autopsy and 10.5% underwent chromosomal microarray analysis. Conclusions The ICD-10 is helpful in classifying the causes of stillbirths, but more than half of the stillbirths in our study were unexplained; therefore, additional work must be done. And the ICD-10 score may need to be improved, such as by classifying stillbirths according to gestational age. Autopsy and CMA could help determine the cause of stillbirth, but the acceptance of these methods is currently low.

Background Investigating the causes of stillbirth is crucial for both parents and healthcare providers as it helps explain why the baby died, guides clinical care in future pregnancies, and aids in developing strategies to prevent stillbirth. The usefulness or utility of investigations for stillbirth is poorly defined and unclear. As a result, protocols for investigating the causes of stillbirth are currently based on clinical consensus and fail to prioritise investigative approaches that are most effective at determining a cause of death. Objectives The objectives of this scoping review were to identify the available evidence, key characteristics, and knowledge gaps regarding the utility of stillbirth investigations. Search strategy An a priori protocol was implemented and included a systematic search in MEDLINE, CINAHL, EMBASE, Scopus, and Cochrane from inception until 28 May 2024. Selection criteria Studies examining stillbirth investigations, yield, and value were included. Data collection and analysis Data were collected using a purpose-built data extraction tool and an analysis was undertaken. Results 57 potentially eligible studies were identified, and 34 studies (with 11,410 stillbirths) were included. Three studies examined clinical utility using a comprehensive testing protocol. Definition of utility or value of investigations varied across the studies, classification system for cause of death and investigation protocols varied. Placental pathology was reported as the most useful investigation in 65%–96% of cases, identified a cause of death in 61–71% of cases and impacting the medical management in 36% of cases (13 studies, 5,169 stillbirths). Autopsy can identify the cause of death in 36–77% of cases and provided new information in 17–26% of cases (17 studies, 4,336 stillbirths). Genetic analysis was useful in 29% of cases (seven studies, 1,886 stillbirths). One study (512 stillbirths) examined the value of investigation by presenting clinical scenario. Conclusions This review indicates that Investigation protocols for stillbirth should include placental pathology, autopsy, and genetic testing. Future studies should address the value of tests by presenting clinical scenarios, use of a consistent definition of stillbirth, classification system and measurement of investigation value.

Background Stillbirth research priorities for Australia were identified in 2015. A renewed priority setting exercise identified current research priorities to address the national burden of stillbirth. Methods Bereaved parents, healthcare professionals, researchers, policymakers, and community-based support organisations participated in this priority setting partnership. Using a modified James Lind Alliance approach, proposed research questions were collated, refined and reviewed against existing evidence, with participants ranking their top ten research questions. Twenty-six key stakeholders at an in-person forum then determined the top research priorities. Results Consultations were attended by 243 participants, representing over 30 community and professional organisations, 219 participated (48% with lived experience of stillbirth) in the prioritisation survey. In the final prioritisation forum 25 research questions were prioritised, and six overarching priority areas identified: (1) Determine the causes of, and pathways that lead to stillbirth; (2) Identify and implement strategies to prevent stillbirth; (3) Build the capacity of health services and systems; (4) Understand and improve care for families after perinatal loss; (5) Ensure culturally safe and responsive care for Aboriginal and Torres Strait Islander families; and (6) Ensure culturally safe and responsive care for families of migrant and refugee background. Conclusion This process identified a relevant stillbirth research agenda to improve outcomes for women and families in Australia.

Background Reports on maternal deaths and stillbirths in health facilities are a critical but underutilized source of information to monitor the quality of care. In addition, with increasing coverage of deliveries by health facilities, such data can improve population estimates of maternal mortality and stillbirth rates. Data quality concerns, however, have often deterred use of facility data. This study aims to assess subnational trends in institutional mortality and examine its utility for improving population-based estimates of mortality. Methods Data from the routine monthly reporting system of the Ministry of Health in Kenya were used to assess levels and trends in maternal mortality and stillbirth rates in 47 counties from 2011 to 2022. Data quality was assessed using multiple methods, including consistency of annual reporting of live births, stillbirths and maternal deaths by counties, plausibility of the ratio of reported stillbirths to maternal death, the county institutional mortality in comparison to delivery coverage, socioeconomic development and health system characteristics. The consistency between institutional and population estimates of mortality was assessed using different scenarios. Results Institutional live birth coverage increased from 64.0% in 2014 to 87.8% in 2022, ranging from 49 to 99% in counties. Kenya and 39 of its 47 counties experienced a decline in institutional maternal mortality ratio and stillbirth rate during the study period 2011–2022. The national institutional maternal mortality decline stagnated from 2018 and was 99 maternal deaths per 100,000 live births in 2022. Consistency of reported data by county was good over time but several indicators suggest that maternal death reporting was incomplete and more so in less-developed counties. Estimates of the population maternal mortality ratio, derived from the facility data, were much lower than global estimates or census results, while the stillbirth rates were consistent. Conclusion The health facility data on maternal death and stillbirths are an important data source for monitoring national and subnational institutional maternal mortality and stillbirth rates and can also inform population estimates. Systematic sustained assessment of reporting completeness will be critical to achieve the full potential of facility data-derived mortality monitoring.

Background Every year, an estimated 2.6 million stillbirths occur worldwide, with up to 98% occurring in low- and middle-income countries (LMIC). There is a paucity of primary data on cause of stillbirth from LMIC, and particularly from sub-Saharan Africa to inform effective interventions. This study aimed to identify the cause of stillbirths in low- and middle-income settings and compare methods of assessment. Methods This was a prospective, observational study in 12 hospitals in Kenya, Malawi, Sierra Leone and Zimbabwe. Stillbirths (28 weeks or more) were reviewed to assign the cause of death by healthcare providers, an expert panel and by using computer-based algorithms. Agreement between the three methods was compared using Kappa (κ) analysis. Cause of stillbirth and level of agreement between the methods used to assign cause of death. Results One thousand five hundred sixty-three stillbirths were studied. The stillbirth rate (per 1000 births) was 20.3 in Malawi, 34.7 in Zimbabwe, 38.8 in Kenya and 118.1 in Sierra Leone. Half (50.7%) of all stillbirths occurred during the intrapartum period. Cause of death (range) overall varied by method of assessment and included: asphyxia (18.5–37.4%), placental disorders (8.4–15.1%), maternal hypertensive disorders (5.1–13.6%), infections (4.3–9.0%), cord problems (3.3–6.5%), and ruptured uterus due to obstructed labour (2.6–6.1%). Cause of stillbirth was unknown in 17.9–26.0% of cases. Moderate agreement was observed for cause of stillbirth as assigned by the expert panel and by hospital-based healthcare providers who conducted perinatal death review (κ = 0.69; p  < 0.0005). There was only minimal agreement between expert panel review or healthcare provider review and computer-based algorithms (κ = 0.34; 0.31 respectively p  < 0.0005). Conclusions For the majority of stillbirths, an underlying likely cause of death could be determined despite limited diagnostic capacity. In these settings, more diagnostic information is, however, needed to establish a more specific cause of death for the majority of stillbirths. Existing computer-based algorithms used to assign cause of death require revision.