Stillbirths and quality of care during labour at the low resource referral hospital of Zanzibar: a case-control study.
To study determinants of stillbirths as indicators of quality of care during labour in an East African low resource referral hospital.



A criterion-based unmatched unblinded case-control study of singleton stillbirths with birthweight ≥2000 g (n = 139), compared to controls with birthweight ≥2000 g and Apgar score ≥7 (n = 249).



The overall facility-based stillbirth rate was 59 per 1000 total births, of which 25 % was not reported in the hospital's registers. The majority of singletons had birthweight ≥2000 g (n = 139; 79 %), and foetal heart rate was present on admission in 72 (52 %) of these (intra-hospital stillbirths). Overall, poor quality of care during labour was the prevailing determinant of 71 (99 %) intra-hospital stillbirths, and median time from last foetal heart assessment till diagnosis of foetal death or delivery was 210 min. (interquartile range: 75-315 min.). Of intra-hospital stillbirths, 26 (36 %) received oxytocin augmentation (23 % among controls; odds ratio (OR) 1.86, 95 % confidential interval (CI) 1.06-3.27); 15 (58 %) on doubtful indication where either labour progress was normal or less dangerous interventions could have been effective, e.g. rupture of membranes. Substandard management of prolonged labour frequently led to unnecessary caesarean sections. The caesarean section rate among all stillbirths was 26 % (11 % among controls; OR 2.94, 95 % CI 1.68-5.14), and vacuum extraction was hardly ever done. Of women experiencing stillbirth, 27 (19 %) had severe hypertensive disorders (4 % among controls; OR 5.76, 95 % CI 2.70-12.31), but 18 (67 %) of these did not receive antihypertensives. An additional 33 (24 %) did not have blood pressure recorded during active labour. When compared to controls, stillbirths were characterized by longer admissions during labour. However, substandard care was prevalent in both cases and controls and caused potential risks for the entire population. Notably, women with foetal death on admission were in the biggest danger of neglect.



Intrapartum management of women experiencing stillbirth was a simple yet strong indicator of quality of care. Substandard care led to perinatal as well as maternal risks, which furthermore were related to unnecessary complex, time consuming, and costly interventions. Improvement of obstetric care is warranted to end preventable birth-related deaths and disabilities.



This is the baseline analysis of the PartoMa trial, which is registered on ClinicalTrials.org ( NCT02318420 , 4th November 2014).
Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353, Copenhagen K, Denmark. nannamaaloe@outlook.com.
Nanna
0000-0002-3443-1277
N
Maaløe
Mnazi Mmoja Hospital, Zanzibar, Tanzania.|Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.
Natasha
N
Housseine
Global Health Section, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Building 9, 1353, Copenhagen K, Denmark.
Ib Christian
IC
Bygbjerg
Mnazi Mmoja Hospital, Zanzibar, Tanzania.|School of Health & Medical Sciences, State University of Zanzibar, P.O.Box:146, Zanzibar, Tanzania.
Tarek
T
Meguid
Mnazi Mmoja Hospital, Zanzibar, Tanzania.
Rashid Saleh
RS
Khamis
Mnazi Mmoja Hospital, Zanzibar, Tanzania.
Ali Gharib
AG
Mohamed
Department of Obstetrics, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark.
Birgitte Bruun
BB
Nielsen
Athena Institute, VU University of Amsterdam, De Boelelaan 1105, 1081 HV, Amsterdam, The Netherlands.
Jos
J
van Roosmalen
D000328:Adult; D016022:Case-Control Studies; D002585:Cesarean Section / Q000592:standards / Q000706:statistics & numerical data; D036861:Delivery, Obstetric / Q000592:standards / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D018743:Perinatal Care / Q000592:standards / Q000706:statistics & numerical data*; D011247:Pregnancy; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D050497:Stillbirth / Q000453:epidemiology*; D013636:Tanzania / Q000453:epidemiology; D055815:Young Adult
Caesarean section; Case-control study; Criterion-based audit; Guidelines; Labour; Low resource; Oxytocin; PartoMa; Partograph; Quality of care; Severe hypertensive disorders; Stillbirths; Tanzania