Amanuel Tebabal
Amanuel Tebabal
Amanuel Tebabal
2021-07
Amanuel, Tebabal
http://ir.bdu.edu.et/handle/123456789/13901
Downloaded from DSpace Repository, DSpace Institution's institutional repository
BAHIR DAR UNIVERSITY
MIDWIFERY DEPARTMENT
JULY, 2021.
The undersigned examining committee certify that the thesis presented by Amanuel Tebabal
entitled: Determinants of stillbirth among mothers who gave birth in Bahir Dar city public
hospitals, Northwest, Ethiopia, 2021, submitted to Bahir Dar University, college of medicine
and health sciences, school of health sciences, department of midwifery, in partial fulfillment
of the requirement for master degree in clinical midwifery compiles with the regulation of the
university and meets the accepted standards with respects to originality and quality.
Place of submission: Midwifery department, College of Medicine and Health sciences, Bahir
Dar University.
Date of submission__________________________
RESEARCH ADVISORS:
Signature_________________, Date_____________________
JULY, 2021
Firstly, I would like to thank Bahir Dar University College of medicine and health science
department of midwifery for creating this opportunity.
Secondly, I would like to express my heartfelt gratitude and appreciation to my advisors Mr.
Amlaku Mulat (Associate professor in clinical midwifery), Mr. Simegnaw Asmer (Assistant
Professor in clinical midwifery) and Mrs. Yeshalem Wubie (Bsc, MPH/RH) for their undue
support, constructive comments and suggestions.
Thirdly, I would like also thank staffs working in documentation and patients file room at
Bahir Dar city public hospitals for their cooperation to give different reports and patient’s
folders regarding this thesis. Finally, I would like to thanks for data collectors and supervisor.
i
Table of Contents
Acknowledgement................................................................................................................................ i
List of tables....................................................................................................................................... iii
List of figures......................................................................................................................................iv
List of Annexes....................................................................................................................................v
Abbreviations and acronyms.............................................................................................................. vi
ABSTRACT...................................................................................................................................... vii
1. INTRODUCTION........................................................................................................................... 1
1.1 background.................................................................................................................................1
1.2 Statement of the problem...........................................................................................................3
1.3 Justification of the study............................................................................................................ 6
1.4. Literature review.......................................................................................................................7
2. OBJECTIVE.................................................................................................................................. 12
3. METHODS.................................................................................................................................... 13
3.1 Study design and period...........................................................................................................13
3.2 Study area................................................................................................................................ 13
3.3 Population................................................................................................................................ 14
3.4 Study variables.........................................................................................................................14
3.5 Operational definition and term...............................................................................................15
3.6 Sample size determination and sampling technique................................................................ 16
3.7. Data Collection Tool...............................................................................................................19
3.8. Data quality assurance............................................................................................................ 19
3.9. Data processing and analysis.................................................................................................. 19
4. ETHICAL CONSIDERATION....................................................................................................20
5. RESULT........................................................................................................................................ 21
6. DISCUSSION................................................................................................................................27
7. LIMITATIONS OF THE STUDY................................................................................................ 30
8. CONCLUSION..............................................................................................................................31
9. RECOMMENDATION................................................................................................................. 32
REFERENCES.................................................................................................................................. 34
ANNEXES.........................................................................................................................................38
ii
List of tables
Table 1: Sample size determination using factors significantly associated with stillbirth.................... 17
Table 2: Demographic and obstetric characteristics of the participants in Bahir Dar city public
hospitals, Amhara region, Northwest, Ethiopia, 2021 (n = 441)........................................................... 21
Table 3: Obstetric complications and maternal health related Characteristics of Participants in Bahir
Dar city public hospitals, Amhara region, Northwest, Ethiopia, 2021 (n = 441).................................. 22
Table 4: Intra-partum and fetal related characteristics of Participants in Bahir Dar city public hospitals,
Amhara region, Northwest, Ethiopia, 2021, (n = 441).......................................................................... 24
Table 5: Multiple Logistic regression analysis for determinants of stillbirth among study participants
in Bahir Dar city public hospitals, Amhara region, Northwest, Ethiopia, 2021 (n = 441).................... 25
iii
List of figures
Figure 1: Conceptual framework which shows the relationship between the dependent and
independent variables............................................................................................................................ 11
Figure 2: Sampling procedure of study participants in Bahir Dar city public hospitals, Amhara region,
Northwest, Ethiopia, 2021..................................................................................................................... 18
iv
List of Annexes
Annex 2: Questionnaires.......................................................................................................... 39
v
Abbreviations and acronyms
CI Confidence Interval
DM Diabetes Mellitus
GA Gestational Age
TT Tetanus Toxoid
vi
ABSTRACT
Back ground: Stillbirth is tragic adverse pregnancy outcomes that cause direct, indirect, and
intangible costs to women, their partners and families, health-care providers, the government,
and the wider society. Almost all stillbirths occur in low and middle income countries.
Attempts to lower the stillbirth rate may be hampered by an incomplete understanding of the
risk factors leading to the majority of stillbirths.
Objective: This study was tried to identify determinants of stillbirth among mothers who
gave birth in Bahir Dar city public hospitals, Amhara region, Northwest, Ethiopia, 2021.
Method: Institution based unmatched case control study was conducted from April 1–
30/2021 among 441(147 cases and 294 controls) charts of mothers. Participant’s folders were
selected by simple random sampling technique. Data from participants’ folder was collected
by data extraction checklist. Data were coded and entered by epi data version 3.1 then
exported into SPSS version 23 for analysis. Binary and Multivariable logistic regression
analyses was employed to estimate the crude and adjusted odds ratio with 95% confidence
interval and p value of less than 0.05 considered statistically significant.
Result: In this study, being referred from other health facility [AOR =1.86, 95% CI 1.09-
3.11], mother who had hypertensive disorder during pregnancy [AOR=3.34, 95% CI 1.76-
6.33],APH [AOR 6.14,95% CI 2.47-15.22] , previous history of still birth [AOR= 3.61, 95%
CI 1.30-17.05] ,Preterm delivery [AOR=2.15, 95% CI 1.09-4.45],and low birth weight
[AOR=3.97, 95% CI 1.83-8.59] were identified as predictors of stillbirth.
Conclusion and recommendation: The determinants of stillbirth in the study area were
being referred from other health facility, previous history of stillbirth, hypertensive disorder
during pregnancy, antepartum hemorrhage, preterm delivery and low birth weight. Therefore,
to tackle these risk factors, efforts must be directed to broaden and decentralize accessibility
of emergency obstetric service, screen and investigate antenatal risk factors and evaluate the
existing referral system.
vii
1. INTRODUCTION
1.1 background
Stillbirth is defined as a fetus born with no sign of life, weighing more than 1000 grams or
with more than 28 completed weeks of gestation. The death is indicated by the fact that after
such expulsion, the fetus does not breathe or show any other evidence of life such as beating
of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles
(1).This definition of stillbirth is based on a definition recommended by WHO for
international comparability and is being used by 193 countries including Ethiopia (2).
Following the development of neonatal intensive care, the definition has changed and varies
between countries. However, epidemiologically, defining and reporting fetal deaths was and
continues to be a challenge. In response, efforts to standardize the definition of stillbirth and
analyze varying reports for application into clinical practice and public health policy are now
being emphasized (3). While the definition and recording of stillbirth varies widely between
countries, most developing countries have tenfold higher rates than developed countries (4).
Stillbirths can be classified based on either physical appearance as macerated and fresh or
time to death as death before labor and death occurs during labor. A “macerated” stillbirth
shows skin and soft tissue changes as discoloration, darkening, redness, peeling and
breakdown; suggesting death was before delivery (antepartum). Fresh stillbirths lack these
changes and are presumed to have occurred in less than 12 hour (intrapartum) (5).
The high rates of stillbirth unquestionably results from poor health services; poor maternal
health, inadequate antenatal and post-partum care. High quality obstetric services, including
better intrapartum fetal monitoring and timely caesarean sections (C/S), have reduced
stillbirth rates in developed countries (6).
Determining the cause of fetal death aids maternal coping, helps to lessen any perceived guilt,
permits more accurate counseling regarding recurrence risk, and prompt therapy or
intervention to prevent a similar outcome in subsequent pregnancies (7). To do so, neonatal
autopsy, chromosomal analysis, and examination of the placenta, cord, and chorioamnionic
membranes are ideal tests in stillbirth evaluation (8).
Global public health efforts were considered a call to action after the recognition that an
estimated 2.65 million stillbirths occur each year and that 98 percent of stillborn fetuses are
1
from low- and middle-income countries. Efforts to highlight its international importance
include the publication of the six-part Lancet stillbirth series (9).
Unfortunately, progress in improving these rates has been slow, as outlined in series from the
Lancet journal subsequent five part progress report, which emphasized the need for dedicated
leadership, measured effects of interventions, and investigation into knowledge gaps (10).
2
1.2 Statement of the problem
In 2015, WHO estimated that 2.7 million stillbirths were estimated worldwide (5). It is a
death that occurs just when parents expect to welcome a new life and important global health
problem affecting over 7000 families every day (18.4 per 1000 total births). This is similar to
the number of early neonatal deaths, and is approximately half of the total child deaths (aged
one to five years) occurring in the same period (11, 12).
Depending on access to and quality of obstetric care, as well as prevalence of antenatal risk
factors, the proportion of stillbirths may vary from country to country. The great majority of
these stillbirths occur in developing countries. The stillbirth rate in south Asia and sub-
Saharan Africa (SSA) is approximately 10 times that of developed countries (29 vs. 3 per
1000 live births) (13).
Almost all (98%) of stillbirths occur in low- and middle-income countries and more than
three quarters of them in South Asia and SSA (10). SSA is particularly affected with about a
third of all cases worldwide and had stillbirth rate of 28.3 per 1000 births. About 880,000
stillbirths occur annually, 60% of which affect poor and rural families; and more than half
occur among conflict and emergency zones where skilled birth attendance and C/S is much
lower than that for urban births (14).
Ethiopia is one of the SSA countries which have a high stillbirth rate, ranging from 25.5–33
per 1,000 live births (15, 16). In the Amhara region, where the study was conducted, the rate
of stillbirth was high in 2017, at 85 per 1,000 live births (17).
According to the world health statistics 2013,stillbirth rate in Ethiopia was 26/1000 deliveries
which is third highest in the east African countries next to Djibouti and Somalia (with
stillbirth rates of 34 & 30 per 1000 births, respectively) and seventh among the ten countries
that account for two-thirds of all stillbirths in the world (18). In 2015, 3,200,000 babies were
born in Ethiopia which is approximately 8700 every day; of which 258 (3%) stillbirths occur
every day, and 97,000 stillbirths occur (19, 20).
The economic consequence of stillbirth which involves all costs of medical care and
investigations at the time of stillbirth and in subsequent pregnancies was estimated 10–70%
greater than the cost of a live birth (21).
Although mothers, partners and their families suffer most of the worse of stillbirth, it has not
all the experiences positive on health care providers. The health care providers also affected
by far-reaching so-called intangible costs personally and professionally. The professional
effect of stillbirth was characterized in the way that professionals attending to a woman who
had a stillbirth may had fear of litigation and disciplinary action; resulting diminished
emotional availability, stress, state of guilt, anger, self-blame, self-doubt,, anxiety, and
sadness (22).
Despite more than 2.7 million stillbirths recorded globally every year is a tragedy for mothers
and their families, the subsequent implications are invisible and under appreciated (5). About
30 years of attention and interventions to newborn survival and safe motherhood worldwide
has remained focus on survival after live birth (23, 24). However stillbirth has been termed an
‘invisible death’ due to being neglected as a public health issue of importance to society and
health policy makers. Is overlooked in many societies as a fitness monitoring both
internationally and often also at the national level. It is not counted in the millennium
development goals, nor tracked by the united nation, nor in the global burden of disease
metrics and now, continue in the sustainable development goal agenda (10, 25). Only recently,
WHO had acknowledged its importance and includes it in ‘100 Core Health Indicators’ and
4
World Health Assembly has targeted the reduction of stillbirths to below 12 per 1000 total
births in 194 countries including Ethiopia by 2030 (26).
Despite rate of stillbirth has declined worldwide, the annual rate of reduction of is 2% which
is much slower than reductions for child and maternal mortality. However, even this
improvement mainly occurred in developed countries, rather than in developing countries
representing a 1.1% decrease per year (19). It is estimated that at the current rate of progress
to tackle the problem, it will take more than 160 years for a pregnant woman in Africa to
have the same chance of her baby being born alive as a woman in a High-Income Country
today (3).
Efforts made in Ethiopia to improve maternal and child health are showing encouraging
results, Stillbirth rate have decreased from 52 deaths per 1000 live births in 2000 (27) to 33
deaths per 1000 pregnancies in 2016 (15). However, to achieve the target of national stillbirth
rates of 12 per 1000 births of Every Newborn Action Plan by 2030, will have to register more
than double the present progress (10, 28).
It remains a huge burden to our country and health systems. There is also increasing concern
that high stillbirth rates in many regions are also being driven by less apparent, possibly
preventable factors (29).To address the problem in our country, its determinant factors should
be understood. Hence the aim of this study was to identify socio-demographic, maternal
health, obstetric, and fetal related factors that possibly result in stillbirth among mothers gave
birth in Bahir Dar city public hospitals.
5
1.3 Justification of the study
Whilst Ethiopia has a high rate of stillbirths, the local influential factors are not fully
understood. Attempts to lower the stillbirth rate further may be hampered by an incomplete
understanding of the risk factors leading to the majority of stillbirths. Lack of a reasonable
explanation of the stillbirth for subsequent counseling also compounds the distress of the
parents. Therefore an improved understanding of the risk factors of stillbirth in ours settings
is an important step for targeting strategies for its reduction as well as improving maternal
and child health care. Studies conducted in the country on determinants stillbirth are limited
in number; and almost all the researches so far are based on single institution -based settings
which provide limited usefulness for generalizing and designing interventions at the health
systems level for addressing the problem as compared to multi-setting studies. Hence it was
within this context that this case-control study was conducted. Additionally this study also
came up with some variables like labor augmentation, maternal Rh factor and non reassuring
fetal heart rate status, which were not studied previously and documented in the study area in
the best knowledge of the investigator.
Data from this study could be crucial for health care professionals to successfully reduce the
incidence of stillbirth; and its impact on mothers by evidence-based interventions delivered
before and during pregnancy, labor, and delivery. The study might also enable program
planners and policymakers to design maternal and child health care services.
6
1.4. Literature review
Advanced maternal age (generally described as the age of 35 years and above) was reported
as a significant risk factor associated with stillbirth in many studies from Nigeria (30),SSA,
(31, 32) and Jimma Ethiopia (33). In a national survey involving deliveries in china, 40 years
or older and teenage mothers were both reported to have an increased risk of stillbirth (34).
Conversely, in a study from Nigeria that examined pattern and correlates of stillbirth in a
hospital setting, young maternal age (<20 years) was reported to increase the risk of stillbirth
(35) .There was also a higher proportion of stillbirths reported among teenage mothers
compared with older mothers in a study conducted at hospital setting in India (36).
Rural residence has also been reported to contribute to the risk of stillbirth in Nepal and
Gambia (37). On the contrary, a community‐based prospective cohort study in Uganda has
reported a significant increase in risk of stillbirth among urban residents (38) .
Factors related to care setting and access have also been reported to influence stillbirth. There
were a number of studies reporting the association between lack of antenatal care and
stillbirth. According to a study in Nepal: inadequate antenatal care increased the risk of
stillbirth (39).Similar results were reported from Nigeria (30), SSA, (31, 32) and Jimma
Ethiopia.(33)
According to retrospective observational study of stillbirths and risk factors in Southern India
referral from another institution had more risk of having a stillbirth as compared to self
admitted mothers. Similar results had also reported by studies conducted in Cameroon (40) ,
Ghana (41), SSA (31) and Oromia Regional State, Southeast Ethiopia (42). However a study
conducted in Jimma, Ethiopia reported a decreased risk of stillbirth among referred mothers
as compared to self admitted mothers (33) .
According to an unmatched case control study at Regional Referral Hospital, Uganda, failure
to use partograph was significantly associated with stillbirths (43). Similar results were
7
reported in studies conducted in Nepal and northwest Ethiopia (39, 44). Another case control
study of determinants of stillbirth in Felege Hiwot referral hospital, Northwest, Ethiopia, not
taking at least two doses of TT vaccine was found to increase risk of stillbirth (44).
APH was other obstetric complications which have been reported to be significantly
associated with stillbirth in studies conducted in Nepal, Nigeria, Cameroon, Northern
Tanzania, southwestern Ethiopia and Amhara region, Ethiopia (30, 39, 40, 49, 50, 53).
Premature rupture of fetal membranes before the onset of labor (PROM) is also identified
determinant factor for stillbirth in studies conducted in katsina, Nigeria , North-west, Ethiopia
and Amhara region, Ethiopia (30, 44, 49).
Labor and delivery related factors associated with stillbirth that were reported by various
studies include obstetric complication during labor (39). Case–control study in Cameroon
(40), and southwestern Ethiopia (53) reported obstructed labor as a risk factor of stillbirth.
Rupturing the uterus during labor was another determinant factor of stillbirth reported in
studies on determinants of stillbirths in katsina, Nigeria and northwest Ethiopia (30, 53).
Other Labor and delivery related factors like delivery by C/S (30, 33), meconium stained
amniotic fluid (42, 49, 52) and cord accidents (43, 54), were also reported as determinants of
stillbirth.
Prematurity(<37 weeks) is reported as a determinant factor by studies done in, India (48),
Nepal (44),Tanzania (50),Cameron (40) Zimbabwe (55),SSA (31), Mizan Tepi, Ethiopia (53),
and central zone ,Tigray, Ethiopia (52). On the other hand, a case-control study of risk
factors for fetal death in a tertiary hospital in Kenya (56) and a cohort study in Northern
Tanzania (50) shows that the odds of stillbirth were higher in both GA less than 37 weeks
and above 42 weeks compared to 37-42 weeks.
A registry-based retrospective cohort study in Northern Tanzania (50), a case control study in
SSA (31) and case control study in Oromia Regional State, Southeast Ethiopia (42) reported
low birth weight (<2500g) increases still birth. On the contrary a study in Zambia, reported
that birth weight ≥4000 g increased the risk for stillbirth (57).
A study done in city of Pato Branco (Brazil) among stillbirths occurred, proportionally more
were male (52.7%) (58). A systematic review and meta-analysis of more than 30 million
births using Vital Statistics in England and Wales also shows risk of stillbirth in males was
elevated by about 10% (59). Another case study of the Trends and risk factors associated with
Stillbirths in Northern Ghana, female neonates were less likely to be stillborn compared to
male neonates (60).However, a study on rates and risk factors of stillbirth in Nigeria based on
2013 Nigeria demographic and health survey (61),large retrospective study from Zimbabwe
that explored delivery patterns and outcomes in a hospital setting (55), and retrospective
observational study in Southern India (62) found no statistically significant difference
between the risk of stillbirth in males and females.
9
Non-cephalic presentation was also reported from study in Northern Tanzania, and a case-
control study on intrapartum stillbirth in public health facilities of Addis Ababa, Ethiopia (63)
to be associated with stillbirth (50).Fetal congenital malformation is found statistically
significant risk of stillbirth in studies done in Katsina, Nigeria(30), SSA (31, 64) and north-
west, Ethiopia (44). A case-control study of stillbirth and associated risk factors in tertiary
care setting of Nepal shows multiple births increased risk for intrapartum stillbirth (39).
10
Conceptual framework
Figure 1: Conceptual framework which shows the relationship between the dependent and
independent variables, adapted from (30-64).
11
2. OBJECTIVE
To identify determinants of stillbirth among mothers who gave birth in Bahir Dar
city public hospitals, Northwest, Ethiopia, 2021.
12
3. METHODS
Institution based unmatched case control study design was conducted from April 1-30/2021
in Bahir Dar city public hospitals, Northwest, Ethiopia.
The study was conducted in Bahir Dar city public hospitals. Bahir Dar city is one of the ten
most beautiful cities in Africa and the capital city of Amhara region, Ethiopia. It is 563 km
far from Addis Ababa. Administratively, the city is divided into 9 sub-cities. The altitude of
the city is between 648 and 1300 meters above sea level. According to the Amhara Bureau of
Finance and Economic Development (BOFED), the population of Bahir Dar city was
estimated to be 339,683. Among these, 156,376(46%) of them are females (65).
The city had one specialized, one referral and one primary government hospitals (Tibebe
Ghion Specialized hospital, Felege Hiwot comprehensive referral hospital, and Addis Alem
primary hospital respectively), 11 health centers (including one private health center),
10 health posts and one family guidance association clinic, 4 private general hospital, and 35
medium private clinics. Among public health facilities 4 public facilities named Tibebe
Ghion Specialized hospital, Felege Hiwot comprehensive referral hospital, and Addis Alem
primary hospital ,Bahir Dar health center, were provide Emergency Obstetric and Newborn
Care service during the study period.
According to the Bahir Dar city zone health department 2010 E.C report, there were 15,208
annual deliveries (65). According to reports from the respective hospitals where data was
collected, total deliveries conducted from January 1/2020 to December 31/2020 was 3472,
5163 and 2604 in Tibebe Ghion specialized hospital (66), Felege Hiwot comprehensive
referral hospital (67),and Addis Alem primary hospital(68) respectively.
13
3.3 Population
The source population was all mothers who delivered from January 1/2020 to December
31/2020 in Bahir Dar city public hospitals.
Cases: were all mothers who gave birth in the last one year in Bahir Dar city public hospitals
and had stillbirth outcome.
Controls: were all mothers who gave birth in the same period in Bahir Dar city public
hospitals and had live birth outcome.
Mothers with unknown GA and birth weight and mothers whose charts didn’t include the
status outcome of new born (dead or alive) were excluded from the study.
Stillbirth
14
Obstetric complications and maternal health related characteristics: STI, HIV sero-
status, hypertensive disorder during pregnancy, maternal DM, APH, polyhydramnious,
oligohydramnious, PROM, chorioamnionitis, Rh factor, and maternal anemia.
Stillbirth was defined in this study as baby born dead after 28 weeks gestation or with ≥1000
grams birth weight which was explained by an APGAR score of 0 at 1st and 5th minutes (39).
Antepartum stillbirth was defined as delivery of any fetus after 28 weeks of gestation, or
with a birth weight ≥1000 grams, with an APGAR score of 0 at 1st and 5th minuets, and signs
of maceration as recorded by the delivering clinician/Or absent fetal heart sound before the
initiation of labor (20, 39).
Intrapartum stillbirth was defined as the delivery of any fetus after 28 weeks of gestation,
or with a birth weight ≥1000 grams, and had an APGAR score of 0 at 1st and 5th minuets,
without signs of maceration as recorded by the delivering clinician/Or had detectable fetal
heart sounds upon labor admission, but died during the intrapartum period and thus had an
APGAR score of 0 at 1st and 5th minuets (20, 39).
Antenatal care attendance was determined based on whether a mother attended ANC visits
during which she received a clinical examination, counseling, and medication (if needed)
from a skilled provider as per guidelines (39).
Gestational age was estimated based on documentation in the medical charts, using the date
of the last normal menstrual period (LNMP) as documented in the hospital record by
Naegele's rule and/or based on ultrasound if was performed before 22+0 weeks of gestation
(49, 69).
15
Partograph use: All the data on the three components of partograph (fetal condition,
progress of labor, and maternal condition) were completed as per WHO protocol, is
considered that a partograph is utilized (70).
Incomplete charts are charts which were found incomplete on major variables under study
(no information about antenatal period, labor status, and delivery summary or procedure
notes) (42).
No reassuring fetal heart rate patterns of a fetus is defined as fetal heart rate below 120
beats/minute (bradycardia) or above 160 beats/minute (tachycardia) for 10 minutes or more
(71).
Cord accidents in this study comprise cord prolapse, cord knots, and tight coil of cord round
the fetal neck (35).
The sample size was calculated based on an unmatched case–control formula by using Epi-
info version-7 Fleiss formula calculator with the assumption of power = 80%, two-sided level
significance= 95%, 1:2 case to control ratio. From previous unmatched case–control study on
determinants of stillbirth (44), a variable STI (percent controls exposed = 1.2 %, AOR = 5.7)
was selected because it was the exposure variable that gave the highest 420 which was the
largest sample size from the alternative significant factors. Adding 5% contingency for
incomplete check list filled by data collectors, the final sample size was 441(147 cases and
294 controls).
16
Table 1: Sample size determination using factors significantly associated with stillbirth.
The allocation of samples to each hospital was determined based on proportion of cases load
(delivery reports) using report from January 1/2020 to December 31/2020; was 3472(83
stillbirth and 3389 live birth), 5163(101 stillbirth and 5062 live birth) and 2604(63 stillbirth
and 2541 live birth) in Tibebe Ghion specialized hospital, Felege Hiwot comprehensive
referral hospital, and Addis Alem primary hospital respectively.
A list of medical registration number was developed separately for cases and controls by
registering medical record number of mothers by taking lists from delivery registration book
in each hospital’s registered from January 1/2020 to December 31/ 2020. Then, the medical
record number of cases and controls was selected randomly from separate lists of cases and
17
controls respectively by using lottery method. Following selection of cases and controls, data
collectors and card room workers had selected charts of mothers from card room using
medial record numbers. Then the data collectors reviewed the woman’s referral, history,
laboratory results, partograph, decision notes, progress notes, delivery summary/procedure
note and operation notes and filled in the checklist. Incomplete charts on major variables
under study (no information about antenatal period, labor status, and delivery summary or
procedure notes) replaced by randomly selected charts in the same facility.
Figure 2: Sampling procedure of study participants in Bahir Dar city public hospitals,
Amhara region, Northwest, Ethiopia, 2021
18
3.7. Data Collection Tool
Data was collected by using pretested and structured checklist which was developed in
English language after thorough literature review(30-64). The checklist consists of relevant
information on socio-demographic data, obstetric history, medical history, delivery history,
birth outcome and fetal related characteristics. Three post-basic 2nd year and three generic 4th
year midwifery students were involved in the data collection and one degree holder midwife
was involved as a supervisor. Both data Collectors and the supervisor were trained for two
days in order to be familiarized to data collection tool.
To ensure quality of data, data collection tool was prepared after intensive review of relevant
literatures. Prior to data collection, the data collectors and the supervisor was given technical
training with a practical session for two days about techniques of sampling, ways of
collecting the data and ethical protocols. Checklist pre-test carried out on 5 %( n=22) of
sample size before the actual data collection at Felege Hiwot comprehensive referral hospital
and modifications of the checklist were made on rephrasing and skipping patterns. The
principal investigator and supervisor had done Continuous follow-up throughout the data
collection period. The collected data was checked for completeness, accuracy and clarity by
supervisor daily and anything which was unclear communicated to the data collectors and
necessary correction was done accordingly to the aims of the study.
After data collection was completed, each completed checklist was given a unique code by
the principal investigator and entered using epidata version 3.1, and then exported to SPSS
version 23 for analysis. The data were cleaned for inconsistencies. Descriptive statistics were
used to summarize the data. Mean and standard deviation was used to describe normally
distributed continuous variables.Comparison of the mean mothers' age, newborn birth weight
and gestational age between cases and controls was done using independent sample t-test.
All assumptions of binary logistic regression were checked accordingly and bivariate analysis
was employed to assess the association between independent and dependent variables.
Multicollinearity test was carried out to see the correlations between predictors of outcome
variables, and did not show any significant collinearity between the risk factors.
19
Multivariable logistic regression was used to identify independent risk factors for stillbirth
and to control for confounding. Variables with p < 0.25 in bivariate analysis were included in
to multivariable logistic regression model. Confidence interval of 95% was used to see the
precision and the level of significance was taken at p value < 0.05. Thus the crude odds ratio
(COR) from bivariate binary logistic regression and adjusted odds ratio (AOR) from
multivariable binary logistic regression is reported. Finally the results were presented using
tables and texts.
4. ETHICAL CONSIDERATION
Ethical clearance for this study was obtained from research and ethical review committee of
Bahir Dar University College of Medicine and Health Science (Protocol No-208/2021) after
submission of the proposal. Written permission letter was also received from collage of
Medicine and health science. Subsequently, a letter of permission was obtained from each
hospital administrators and sent to each hospital maternal health units and medical record
departments. The objective of the study was explained to the head of each unit and
administrators of the hospitals.
Strict attention was paid to the selected charts of study participants during the data collection,
until written handover for chartroom workers at the end of the data collection. In order to be
confidential only the code, not personal identifiers such as name and phone numbers have
been taken from the charts. All information taken from the client charts were kept
confidential and only investigator had access to the information which was used only for the
purpose of this study.
20
5. RESULT
A total of 441 study participants were included, making a response rate of 100%. The age of
the respondents ranges 18-42 both in cases and controls. Around half 73(49.7%) of cases and
186(63.3%) of controls are urban residents. Regarding admission status 120 (81.6%) of cases
and 204(69.4%) of controls are referred from other health facilities.
One hundred forty (95.2%) of cases and 284(96.6%) of controls had ANC visits during their
pregnancy and 138 (93.9%) of cases and 284 (96.9%) of controls took at least two doses of
TT vaccine (Table 2).
Table 2: Demographic and obstetric characteristics of the participants in Bahir Dar city public
hospitals, Amhara region, Northwest, Ethiopia, 2021 (n = 441).
No (%) No (%)
≥ 35 17(11.5) 23(7.8)
No 7 (4.8) 10(3.4)
No 9 (6.1) 10(3.4)
21
Iron-folate intake Yes 136(92.5) 285(96.9)
No 11(7.5) 9(3.1)
No 130(88.4) 258(87.8)
No 30(24.2) 69(55.6)
Among the study participants, 3(2%) of cases and 6(2%) of controls had history of STI;
Whereas 6(4.1%) and 7(2.2 %) of cases and controls are living with HIV respectively. Forty
three (29.3%) of cases and 8(2.7%) of controls were had APH during current pregnancy.
About 50 (34%) of cases and 24(8.2%) of controls had hypertensive disorder during current
pregnancy (Table 3).
22
HIV Sero-status Non Reactive 131(89.1) 263(89.4)
Reactive 6(4.1) 7(2.4)
Unknown 10(6.8) 24(8.2)
Indicates that (spontaneous uterine scar dehiscence and local cause (cervical tear/laceration before
**
delivery).
From a total of 147 cases 78(53.1%) and 69(46.9%) was antepartum (macerated) and
Intrapartum (fresh) stillbirths respectively. Almost all 140(95.2 %) and 281 (95.6%) of cases’
and control’s labor was started spontaneously, and 11(7.5%) of case’s and 20(6.8%) of
control’s labor was augmented.
23
The mean GA among cases were 36+5 weeks (SD ± 3+6 weeks) and 39 (SD± 2+3weeks among
controls. There is a statistically significant difference in mean GA among cases and controls
(p<0.001).Regarding birth weight, mean birth weight among cases were 2.5 kg and 3 kg
among controls. There is a statistically significant difference in mean birth weight among
cases and controls (p<0.001) (Table 4).
Table 4: Intra-partum and fetal related characteristics of Participants in Bahir Dar city public
hospitals, Amhara region, Northwest, Ethiopia, 2021, (n = 441).
Variable Categories Case (n= 147) Control (n=294)
No (%) No (%)
24
Birth weight of Low Birth Weight(<2500g) 74(50.3) 19(6.5)
newborn Normal Birth Weight (2500-4000g) 68(46.3) 265(90.1)
Macrocosmic(>4000g) 5(3.4) 10(3.4)
Fetal congenital Yes 9(6.1) 1(0.3)
anomaly No 138 (93.9) 293(99.7)
Type of Neural Tube Defect 4(40.0) 1(10.0)
anomaly(n=10) Chari II malformation 2(20.0) 0
Ventriculomegaly 2(20.0) 0
Dandy-Walker syndrome 1(10.0) 0
Sex of newborn Female 62(42.2) 127(43.2)
Male 85(57.8) 167(56.8)
*
Elective C/S and C/S at latent first stage of labor,
**
Assisted breech, forceps, vacuum, destructive, laparatomy
However after adjusting for confounding factors in multivariable binary logistic regression
analysis; by using enter method mother who were referred from other health facility [AOR
=1.86, 95% CI 1.09-3.11], mother who had hypertensive disorder during pregnancy
[AOR=3.34, 95% CI 1.76-6.33],APH [AOR 6.14,95% CI 2.47-15.22] , previous history of
still birth [AOR= 3.61, 95% CI 1.30-17.05] ,Preterm delivery [AOR=2.15, 95% CI 1.09-
4.45],and low birth weight [AOR=3.97, 95% CI 1.83-8.59] were the risk factors for
stillbirths in the study area (Table 5).
Table 5: Multiple Logistic regression analysis for determinants of stillbirth among study
participants in Bahir Dar city public hospitals, Amhara region, Northwest, Ethiopia, 2021 (n
= 441).
Cases No Controls
25
(%) No (%)
Age <25 15 (10.2) 34 (11.6) 1 1
25-34 108 (73.5) 237 (80.6) 1.03[0.54-1.97] 1.01[0.59- 1.15] 0.456
≥ 35 24 (16.3) 23 (7.8) 2.36[1.02-5.44] 1.76[0.58-5.29] 0.310
26
6. DISCUSSION
In this unmatched case control study, access to care, maternal health, obstetric related and
fetal related factors were identified as predictors of stillbirth.
Odds of experiencing stillbirth were 1.86 fold higher among mothers who were referred from
other health facilities compared to those who came from home. The finding was consistent
with the studies conducted in SSA, Cameroon and Ghana (31, 40, 41). This could be due to
the reason that most of the referred cases came from rural peripheral health facilities and
might be after having serious complications. The distance to reach the hospitals to which they
were referred contributes to delay in receiving care, which increases the chance that the fetus,
even if alive at referral from a lower level facility, will be dead by the time a woman reaches
the referral facility, especially if fetal distress is a complication(41).This finding is in contrast
to the study done in Jima University Specialized Hospital, Ethiopia reported a decrement in
stillbirth by 70% among those referred pregnant women from other health facility compared
to those not referred (33). The difference might be due to the differences in study area, study
period, study design and/or sample size.
Mothers who experience hypertensive disorder during pregnancy had 3.34 times high odds
of stillbirth as compared to their counterparts. The association between hypertensive disorder
during pregnancy and stillbirth was also demonstrated by a good number of similar studies in,
Tigray, Ethiopia (52), North Shewa Zone, Oromia region, Ethiopia (51), SSA (31),Nigeria
(30),Tanzania (50),and Cameron (40). The association between hypertensive disorder during
pregnancy and stillbirth is physiologically plausible and had been well described in literatures.
This usually leads to utero—placenta insufficiency due to impaired remodeling of the spiral
artery could lead to chronic fetal insult, intrauterine growth restriction and consequently
intrauterine fetal death (50). This may further explained by the result of utero-placental
insufficiency which causes, placental infarction, abruptio placenta or fetal-maternal
hemorrhage. Due to those reasons, maternal hypertension may decrease fetal growth
consequently fetal death. Fetal-maternal hemorrhage causes elevated maternal serum α-
fetoprotein found to be a marker of stillbirth (52).
APH increase the odds of stillbirth six fold than no APH. This finding was in line with the
studies conducted in southwestern Ethiopia, Nigeria, Cameroon, Northern Tanzania, and
Nepal (30, 39, 40, 50, 53). The possible explanation might be that even severe forms of APH
27
usually may not manifest any form of apparent external bleeding but stayed as concealed
hemorrhage. Then those forms of APH, where the babies can survive may not readily detect,
or because of late presentation to hospitals, the APH progress to more severe forms before
they are seen in health facilities. This may reduce the chance of salvaging babies from life
threatening rapidly developing anemia leads to decrease in fetal oxygenation and asphyxia
which results in intrauterine fetal death (30).
Mothers who had a previous history of stillbirth were 3.61 times higher odds of experiencing
stillbirth compared to their counterparts. This finding was in line with the studies conducted
North-west, Ethiopia, SSA, Nepal and India, (31, 32, 44, 47, 48). The reason might be due to
the assumption that the mother might have undiagnosed chromosomal abnormalities that
cause recurrent fetal death. Another possible reason could be the presence of undiagnosed
maternal chronic and repeated co morbidities that can causes unexplained recurrent fetal
death (44).
Preterm newborns had 2.15 higher odds of born died as compared with newborn delivered at
term. This study is in line with previous studies in central zone of Tigray, Ethiopia (52) and
Mizan Tepi, Ethiopia (53), SSA (31), Zimbabwe (55) ,Cameron (40), Tanzania (50) and
Nepal (44) which discovered that preterm babies were more at risk of being stillborn. The
possible reason for this might be due to the fact that premature infants are more susceptible to
ischemia, due to incomplete blood-brain barrier formation. It may also be due to the fact that
preterm babies face multiple morbidities, including organ system dysfunction due to
immaturity, especially lung immaturities causing respiratory failure asphyxiated , distressed
and lead them to stillbirth (52).Moreover Preterm birth is a pathway frequently with
underlying placental insufficiency, or intra-uterine growth retardation; in which a
compromised fetus copes less to withstand labor and transition to extra-uterine life resulting
in an intra-partum stillbirth, or may result in failure to go into preterm labor leading to
antepartum death (48).
The odd of still birth were four times higher among low birth weight relative to new born
who had normal birth weight. The finding of this study was consistent with the studies
conducted in Oromia Regional State, Southeast Ethiopia (42), SSA (31) and Northern
Tanzania (50). This may be because low birth weight may result from both fetal growth
restriction and preterm birth. Multifaceted public health problem that includes long-term
maternal malnutrition, ill health (hypertension, pre gestational diabetes mellitus, infections),
28
and poor health care that present pre-conception or during pregnancy which all can result
intrauterine growth restriction, increases the risk of the fetus not getting enough oxygen or
other important nutrients and stillbirth (42).
Finally new variables that this study came up with (labor augmentation, maternal Rh factor
and non reassuring fetal heart rate status) were not associated with stillbirth in this study.
29
7. LIMITATIONS OF THE STUDY
First, this study used hospital-based data which had already been recorded for clinical
purpose and not specifically meant for this study. Then we had no control for variables which
were not recorded on maternal records despite that they were important in the present study.
The study was facility based and can’t be generalized for the stillbirth occurred at community
level.
30
8. CONCLUSION
Being referred from other health facility, previous history of stillbirth, hypertensive disorder
during pregnancy; APH, preterm delivery and low birth weight were identified determinants
of stillbirth in the study area.
31
9. RECOMMENDATION
Based on the findings of this study the following recommendations are forwarded.
Federal Government
It is better if the government give emphasis to decentralize health care provision centers to
address accessibility of specialized and emergency obstetric care; and facilitate
infrastructures needed to improve ease of emergency referral systems.
Federal ministry of health and Amhara regional state health bureau recommend to evaluating
the existing referral system and supervising health facilities on its proper use and
implementation.
We also recommended public hospitals in Bahir Dar city to have electronic data storage.
We recommend district and private hospitals, and health centers to establish a minimum
package for basic emergency obstetric and neonatal care to manage identified risk factors
without need of referral.
Primary and private hospitals and health centers are better to have facility evaluation system
about whether they are referring patients on time and with appropriate communications or not.
Health professionals
We recommended health professionals to give close follow up in subsequent pregnancies if
the woman has a history of stillbirth.
32
It is also better if health professionals use ANC follow-up as an opportunity to screen and
investigate antenatal risk factors for stillbirth, as well as to provide counseling to women
about danger symptoms and the need for early hospital arrival; and thus, help to ensure a
successful pregnancy outcome.
Health extension workers are recommended to teach mothers and people who are around
mothers to be ready for any complication that may arise during pregnancy and labor and seek
care from health institutions.
For researcher
This study is only a step forward to identify determinants of stillbirth, among mothers gave
birth in Bahir Dar city public hospitals. It is therefore understood that this study is not an
ultimate one. Thus, we recommend prospective studies in the area; and also the impact of
stillbirth and its preventive strategies at the community level.
NGOs
We recommend NGOs active is the area to give priorities for stillbirth prevention.
33
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37
ANNEXES
Topic: Determinants of still birth among mothers who gave birth in Bahir Dar city public
hospitals, Northwest, Ethiopia, 2021.
Institution: Bahir Dar University, School Of Health Science, College of Medicine and
Health Science, Department of Midwifery.
Mobile: +251923465114
Email: amantbbl@gmail.com
Stillbirth is one of the most important adverse pregnancy outcomes that cause direct, indirect,
and intangible costs to women, their partners and families, health-care providers, the
government, and the wider society. Almost all stillbirths occur in low and middle income
countries. The aim of this study was to identify determinants of stillbirth among mothers who
give birth in Bahir Dar city public hospitals, Northwest, Ethiopia, 2021.
38
Annex 2: Questionnaires
102. Residence
1. Rural
2. Urban
1. Self-admitted
2. Referred from other facilities
1. No
2. Yes
106. If Q 105 is yes, how many ANC visits did a mother have? _______________
1. No
2. Yes
1. No
2. Yes
39
1. No
2. Yes
1. Induced
2. Spontaneous
1. No
2. Yes
201. Did mother have sexually transmitted infection? (If No skip to 203)
1. No
2. Yes
1. Non reactive
2. Reactive
3. unknown
1. No
2. Yes
1. Eclampsia
2. Preeclampsia
3. Superimposed Preeclampsia
4. Chronic hypertension
5. Gestational hypertension
40
206. Maternal DM?
1. No
2. Yes
1. Rh Positive
2. Rh Negative
1. No
2. Yes
1. Abruption
2. Placenta Prevea
3. Vasa prevea
4. Other causes
1. No
2. Yes
1. No
2. Yes
1. No
2. Yes
1. Term
2. Pre term
41
214. Does mother experience Chorioamnionitis?
1. No
2. Yes
1. Yes
2. No
301. What was the birth outcome? (If live birth, skip to 303)
1. Live birth
2. Stillbirth
302. If outcome was stillbirth, what was the physical appearance of still birth?
1. Fresh
2. Macerated
1. Spontaneous
2. Induced
3. Elective C/S
304. Partograph use during follow up
1. No
2. Yes
3. Came in second stage
4. C/S before active labor
1. No
2. Yes
1. G I
2. G II
3. G III
308. Non reassuring fetal heart rate was detected? (If No skip to 310)
1. No
2. Yes
309. If there was none reassuring fetal heart rate, what was the abnormality?
1. Fetal tachycardia
2. Fetal bradycardia
1. No
2. Yes
1. No
2. Yes
1. No
2. Yes
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5. C/S
6. Destructive
7. Laparatomy
1. Single
2. Twin and above
1. Cephalic
2. Non-cephalic
1. No
2. Yes
1. Female
2. Male
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Annex 3: Declaration form
Declaration
I, the under signed, declared that this is my original work, has never been presented in
this or any other University, and that all the resources and materials used for the
research, have been fully acknowledged.
Principal investigator
Name: _________________________________________
Signature: _________________________________________
Date: __________________________________________
Advisors
1. Name: _________________________________________
Signature: _________________________________________
Date: _________________________________________
2. Name: _________________________________________
Signature: _________________________________________
Date: _________________________________________
3. Name: _________________________________________
Signature: _________________________________________
Date: _________________________________________
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Annex 4: Principal investigator assurance
I certify that the statements herein are true, complete, and accurate to the best of my
knowledge. I certify that individuals or organizations named herein are aware of their planned
or potential involvement. I agree to accept responsibility for the scientific conduct of this
research and to provide the required progress reports if needed.
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Annex 5: spss outputs of statistical normality tests
Std.
N Minimum Maximum Mean Deviation Skewness Kurtosis
Std. Std.
Statistic Statistic Statistic Statistic Statistic Statistic Error Statistic Error
maternal age 441 18 42 26.37 5.152 .740 .116 .514 .232
Birth Weight 441 1.0 4.5 2.812 .6839 -.461 .116 .576 .232
Gestational age in
441 29.0 45.5 38.262 3.0189 -.893 .116 .784 .232
weeks
Valid N (listwise) 441
Descriptive statistics showing the data was normally distributed (skewness and kurtosis z values in the
span of -1.96 to +1.96)
Normal Q-Q plots for maternal age visually indicate that the data is normally distributed.
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Normal Q-Q plots for Gestational age visually indicate that the data is normally distributed.
48