Stillbirths in Nigeria4 October 2022
Stillbirth is defined by the World Health Organisation as ‘a baby born with no signs of life at or after 28 weeks’ gestation’ and are reported as one of the most neglected tragedies in global health today. Each year almost 2m stillbirths occur, the majority occurring in low- and middle-income countries (LMICs), approximately 75% occur in both sub-Saharan Africa and south Asia. UNICEF report that mothers in LMICs seven times more likely to deliver a stillborn baby than their Western European counterparts.
We know around half of stillbirths in LMICs occur during the labour/birth (intrapartum) and many are linked to obstetric complications, a stark contrast to high-income countries where intrapartum stillbirths are rare. Antenatal stillbirths (before labour/birth) are responsible for the other half and are often due to preventable conditions such as infections and non-communicable diseases.
The risk factors for stillbirths we know about include young or advancing maternal age, fetal infection, maternal health, such as hypertension (high blood pressure), perinatal asphyxia (a lack of blood flow or gas exchange to or from the fetus in the period immediately before, during, or after the birth process), history of previous stillbirth and obstetric complications. Commonly reported non-clinical risk factors include low levels of maternal education, socioeconomic deprivation, and substandard antenatal care.
Nigeria is reported to have one of the highest stillbirth rates on the African continent. In addition to these data, it is reasonable to assume that the reported rates are an underestimation due to the cultural challenges faced in LMICs surrounding the reporting of stillbirths. Obtaining reliable and accurate data requires known gestational age at birth, a clear definition of a stillbirth, an increase in facility-based births, and reliable reporting systems both in-facility and communities and a reduction of unattended homebirths; many of these aspects are underdeveloped in LMICs.
The catalyst for our research came about via an observational study looking at neonatal sepsis in LMICs, this study excluded stillbirths from its cohort. A research nurse in one of the study sites highlighted the unacceptably high rates of stillbirth and contacted me requesting we come up with a way of monitoring the numbers. This study site was the Murtala Mohammed Specialist Hospital (MMSH), Kano Nigeria. A tertiary referral hospital located in Kano, Nigeria which is owned by the state Government offering free services. There are 133 maternity beds and 22 delivery cubicles and every month approximately 550 deliveries. There are four midwives on each shift, two allocated to complicated deliveries and two for uncomplicated deliveries. The MMSH is a multi-disciplinary hospital and used as a referral hospital by many surrounding states and some neighbouring countries, contributing to the hospital being extremely under-resourced, the hospital anticipates is supports a population of 11 million.
To date we have undertaken three separate research studies at this site, a case-control study (study one), a prospective cohort study (study two) and a feasibility study (study three), the feasibility study was the only study we received funding for.
Studies one and two are published together: https://www.frontiersin.org/articles/10.3389/fgwh.2021.788157/full
‘A feasibility study: Stillbirths in Kano’, the primary objective being to identify whether stillborn babies in MMSH can be classified using an established system. This study included qualitative, clinical epidemiology, microbiology, and immunology components.
Qualitative: the qualitative work has been published in BMC Pregnancy and Childbirth: https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-021-04207-4
Clinical epidemiology: We carried out a prospective observational feasibility study over three months. Demographic and clinical data were collected from 1998 neonates and 1926 mothers. Of the 1998 births, 1789 were livebirths and 209 were stillbirths, of these 100 had signs of maceration and 109 did not. Signs of maceration were recorded in notes and photographed to assist classification of stillbirth back in the UK. The incidence of stillbirth was 105/1000 births. We found that higher odds of stillbirth were associated with low-levels of maternal education, a further distance to travel to the hospital, living in a shack, maternal hypertension, and previous stillbirth, birthing complications, increased duration of labour, antepartum haemorrhage, prolonged or obstructed labour, vaginal breech delivery, emergency caesarean-section, and signs of trauma to the baby. This work has been published: https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-022-04971-x
Microbiology: We collected head and ear swabs and blood from umbilical cords to conduct microbiological analysis, unfortunately the results were heavily contaminated and unusable. Despite the samples not being able to be used the feasibility and practicality of collecting these samples was successful.
Immunology: We successfully collected 413 pin prick blood samples from mothers to test immunological markers; these were shipped over to Cardiff University to be analysed by Project Sepsis. The results on the few which have been tested were good and able to be used, however analysis on the full sample is yet to be completed due to insufficient funds.
The impact of this work is very hard to quantify, there were media reports, radio broadcasts and newspaper articles and have been peer reviewed articles published. For me as a researcher the biggest impact achieved was understanding that the mothers living in this area were keen for change, and the acceptance to participate in such research amidst such devastating circumstances shows the need for change and understanding that stillbirth can be preventable.
The catalyst for this work was a research nurse identifying how many stillbirths were occurring and that this felt terrifyingly high for her. She contacted me as we were working on a different study together and said she felt helpless and unsure what to do, so as a team we came up with a plan to firstly understand how much of a problem this was. Working on this study was undeniably difficult, from the numbers, the experiences, and then the analysis of the photos and focus groups, but knowing what these researchers were doing situated in the hospital recruiting these mothers and their babies into the study, taking samples from the stillborn babies, and the mothers delivering the babies going through physical and emotional trauma and still signing up to a research study – all for the want to make a change made our side of the research seem really rather inferior.
For more information, please contact Rebecca Milton at MiltonRL1@cardiff.ac.uk
The Centre for Trials Research is a UKCRC-registered clinical trials unit. It is publicly-funded to enable applied research that informs policy in health and social care in Wales and the UK, and is currently running studies across Wales, the UK and internationally. The Centre is funded through Welsh government by Health and Care Research Wales, and Cancer Research UK.