title: Causes of and factors associated with stillbirth in low- and middle-income countries: a systematic literature review.
abstract: BACKGROUND
  Annually, 2.6 million stillbirths occur worldwide, 98% in developing countries. It is crucial that we understand causes and contributing factors.
  
  
  METHODS
  We conducted a systematic review of studies reporting factors associated with and cause(s) of stillbirth in low- and middle-income countries (2000-13). Narrative synthesis to compare similarities and differences between studies with similar outcome categories.
  
  
  RESULTS
  A total of 142 studies with 2.1% from low-income settings were investigated; most report on stillbirths occurring at health facility level. Definition of stillbirth varied; 10.6% of studies (mainly upper middle-income countries) used a cut-off point of ≥22 weeks of gestation and 32.4% (mainly lower income countries) used ≥28 weeks of gestation. Factors reported to be associated with stillbirth include poverty and lack of education, maternal age (>35 or <20 years), parity (1, ≥5), lack of antenatal care, prematurity, low birthweight, and previous stillbirth. The most frequently reported cause of stillbirth was maternal factors (8-50%) including syphilis, positive HIV status with low CD4 count, malaria and diabetes. Congenital anomalies are reported to account for 2.1-33.3% of stillbirths, placental causes (7.4-42%), asphyxia and birth trauma (3.1-25%), umbilical problems (2.9-33.3%), and amniotic and uterine factors (6.5-10.7%). Seven different classification systems were identified but applied in only 22% of studies that could have used a classification system. A high percentage of stillbirths remain 'unclassified' (3.8-57.4%).
  
  
  CONCLUSIONS
  To build capacity for perinatal death audit, clear guidelines and a suitable classification system to assign cause of death must be developed. Existing classification systems may need to be adapted. Better data and more data are urgently needed.
authors.affiliation: Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
authors.forename: M
authors.initials: M
authors.lastname: Aminu
authors.forename: R
authors.initials: R
authors.lastname: Unkels
authors.forename: M
authors.initials: M
authors.lastname: Mdegela
authors.forename: B
authors.initials: B
authors.lastname: Utz
authors.forename: S
authors.initials: S
authors.lastname: Adaji
authors.forename: N
authors.initials: N
authors.lastname: van den Broek
mesh_terms: D002423:Cause of Death; D003906:Developing Countries; D005260:Female; D005865:Gestational Age; D006297:Health Services Accessibility / Q000706:statistics & numerical data; D006801:Humans; D008423:Maternal Age; D008427:Maternal Health Services / Q000706:statistics & numerical data; D010298:Parity; D011247:Pregnancy; D011248:Pregnancy Complications / Q000453:epidemiology; D050497:Stillbirth / Q000453:epidemiology*
keywords: Causes of stillbirth; factors associated with stillbirth; low income countries; middle income countries; stillbirth classification