title: Clinical interventions to reduce stillbirths in sub-Saharan Africa: a mathematical model to estimate the potential reduction of stillbirths associated with specific obstetric conditions.
abstract: OBJECTIVE
  Stillbirths are among the most common adverse pregnancy outcomes, with 98% occurring in low-income countries. More than one-third occur in sub-Saharan Africa (SSA). However, the medical conditions causing stillbirths and interventions to reduce stillbirths from these conditions are not well documented. We estimated the reductions in stillbirths possible with combinations of interventions.
  
  
  METHODS
  We developed a computerised model to estimate the impact of various interventions on stillbirths caused by the most common conditions. The model considered the location of obstetric care (home, clinic or hospital) and each intervention's efficacy, penetration and utilisation. Maternal transfers were also considered.
  
  
  METHODS
  Pregnancies in SSA in 2012.
  
  
  METHODS
  For each condition, we created a series of scenarios involving different combinations of interventions and modelled their impact on stillbirth rates.
  
  
  METHODS
  Stillbirths associated with various maternal and fetal conditions and the percentage reduction with various interventions.
  
  
  RESULTS
  Eight to ten maternal and fetal conditions were responsible for most stillbirths, but none for more than 15%. The most common conditions causing stillbirths in SSA include obstructed labour and uterine rupture, fetal distress and umbilical cord complications, fetal growth restriction, pre-eclampsia/eclampsia, and placental abruption/placenta praevia. Syphilis and malaria contribute smaller numbers. Reducing stillbirths requires appropriate diagnosis and management of each condition, usually including hospital care for monitoring and delivery, often by caesarean section. Maternal syphilis and malaria were the only conditions for which outpatient management alone reduced stillbirth.
  
  
  CONCLUSIONS
  Most stillbirths in low-income countries occur at term and during labour and therefore are preventable by appropriate obstetric care. Management focused on the maternal and fetal conditions that cause stillbirths is necessary to achieve stillbirth rates approaching those found in high-income countries.
  
  
  CONCLUSIONS
  Reducing stillbirth incidence requires appropriate management of each causative condition and often caesarean delivery.
authors.affiliation: Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA.
authors.forename: R L
authors.initials: RL
authors.lastname: Goldenberg
authors.affiliation: Statistical, Social and Environmental Health Sciences, RTI International, Durham, NC, USA.
authors.forename: J B
authors.initials: JB
authors.lastname: Griffin
authors.affiliation: Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA.
authors.forename: B D
authors.initials: BD
authors.lastname: Kamath-Rayne
authors.affiliation: Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA.
authors.forename: M
authors.initials: M
authors.lastname: Harrison
authors.affiliation: Statistical, Social and Environmental Health Sciences, RTI International, Durham, NC, USA.
authors.forename: D J
authors.initials: DJ
authors.lastname: Rouse
authors.affiliation: Statistical, Social and Environmental Health Sciences, RTI International, Durham, NC, USA.
authors.forename: K
authors.initials: K
authors.lastname: Moran
authors.affiliation: Statistical, Social and Environmental Health Sciences, RTI International, Durham, NC, USA.
authors.forename: B
authors.initials: B
authors.lastname: Hepler
authors.affiliation: Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA.
authors.forename: A H
authors.initials: AH
authors.lastname: Jobe
authors.affiliation: Statistical, Social and Environmental Health Sciences, RTI International, Durham, NC, USA.
authors.forename: E M
authors.initials: EM
authors.lastname: McClure
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D005260:Female; D006801:Humans; D008427:Maternal Health Services; D008962:Models, Theoretical; D007744:Obstetric Labor Complications / Q000517:prevention & control; D017063:Outcome Assessment, Health Care; D011247:Pregnancy; D011248:Pregnancy Complications / Q000517:prevention & control; D011256:Pregnancy Outcome; D011295:Prenatal Care; D050497:Stillbirth / Q000453:epidemiology*
keywords: Mortality; stillbirth; sub-Saharan Africa