title: Stillbirth rates in low-middle income countries 2010 - 2013: a population-based, multi-country study from the Global Network.
abstract: BACKGROUND
  Stillbirth rates remain nearly ten times higher in low-middle income countries (LMIC) than high income countries. In LMIC, where nearly 98% of stillbirths worldwide occur, few population-based studies have documented characteristics or care for mothers with stillbirths. Non-macerated stillbirths, those occurring around delivery, are generally considered preventable with appropriate obstetric care.
  
  
  METHODS
  We undertook a prospective, population-based observational study of all pregnant women in defined geographic areas across 7 sites in low-resource settings (Kenya, Zambia, India, Pakistan, Guatemala and Argentina). Staff collected demographic and health care characteristics with outcomes obtained at delivery.
  
  
  RESULTS
  From 2010 through 2013, 269,614 enrolled women had 272,089 births, including 7,865 stillbirths. The overall stillbirth rate was 28.9/1000 births, ranging from 13.6/1000 births in Argentina to 56.5/1000 births in Pakistan. Stillbirth rates were stable or declined in 6 of the 7 sites from 2010-2013, only increasing in Pakistan. Less educated, older and women with less access to antenatal care were at increased risk of stillbirth. Furthermore, women not delivered by a skilled attendant were more likely to have a stillbirth (RR 2.8, 95% CI 2.2, 3.5). Compared to live births, stillbirths were more likely to be preterm (RR 12.4, 95% CI 11.2, 13.6). Infants with major congenital anomalies were at increased risk of stillbirth (RR 9.1, 95% CI 7.3, 11.4), as were multiple gestations (RR 2.8, 95% CI 2.4, 3.2) and breech (RR 3.0, 95% CI 2.6, 3.5). Altogether, 67.4% of the stillbirths were non-macerated. 7.6% of women with stillbirths had cesarean sections, with obstructed labor the primary indication (36.9%).
  
  
  CONCLUSIONS
  Stillbirth rates were high, but with reductions in most sites during the study period. Disadvantaged women, those with less antenatal care and those delivered without a skilled birth attendant were at increased risk of delivering a stillbirth. More than two-thirds of all stillbirths were non-macerated, suggesting potentially preventable stillbirth. Additionally, 8% of women with stillbirths were delivered by cesarean section. The relatively high rate of cesarean section among those with stillbirths suggested that this care was too late or not of quality to prevent the stillbirth; however, further research is needed to evaluate the quality of obstetric care, including cesarean section, on stillbirth in these low resource settings.
  
  
  BACKGROUND
  Clinicaltrials.gov (ID# NCT01073475).
authors.forename: Elizabeth M
authors.initials: EM
authors.lastname: McClure
authors.forename: Sarah
authors.initials: S
authors.lastname: Saleem
authors.forename: Shivaprasad S
authors.initials: SS
authors.lastname: Goudar
authors.forename: Janet L
authors.initials: JL
authors.lastname: Moore
authors.forename: Ana
authors.initials: A
authors.lastname: Garces
authors.forename: Fabian
authors.initials: F
authors.lastname: Esamai
authors.forename: Archana
authors.initials: A
authors.lastname: Patel
authors.forename: Elwyn
authors.initials: E
authors.lastname: Chomba
authors.forename: Fernando
authors.initials: F
authors.lastname: Althabe
authors.forename: Omrana
authors.initials: O
authors.lastname: Pasha
authors.forename: Bhalachandra S
authors.initials: BS
authors.lastname: Kodkany
authors.forename: Carl L
authors.initials: CL
authors.lastname: Bose
authors.forename: Mabel
authors.initials: M
authors.lastname: Berreuta
authors.forename: Edward A
authors.initials: EA
authors.lastname: Liechty
authors.forename: K
authors.initials: K
authors.lastname: Hambidge
authors.forename: Nancy F
authors.initials: NF
authors.lastname: Krebs
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Derman
authors.forename: Patricia L
authors.initials: PL
authors.lastname: Hibberd
authors.forename: Pierre
authors.initials: P
authors.lastname: Buekens
authors.forename: Albert
authors.initials: A
authors.lastname: Manasyan
authors.forename: Waldemar A
authors.initials: WA
authors.lastname: Carlo
authors.forename: Dennis D
authors.initials: DD
authors.lastname: Wallace
authors.forename: Marion
authors.initials: M
authors.lastname: Koso-Thomas
authors.forename: Robert L
authors.initials: RL
authors.lastname: Goldenberg
mesh_terms: D000328:Adult; D001724:Birth Weight; D036861:Delivery, Obstetric / Q000379:methods; D003906:Developing Countries; D004522:Educational Status; D005260:Female; D005865:Gestational Age; D006801:Humans; D007182:Income; D007223:Infant; D007226:Infant Mortality / Q000639:trends*; D007231:Infant, Newborn; D008297:Male; D008423:Maternal Age; D011247:Pregnancy; D011295:Prenatal Care / Q000706:statistics & numerical data; D011446:Prospective Studies; D012042:Registries; D012307:Risk Factors; D050497:Stillbirth / Q000453:epidemiology*; D055815:Young Adult