title: The antepartum stillbirth syndrome: risk factors and pregnancy conditions identified from the INTERGROWTH-21stProject.
abstract: OBJECTIVE
  To identify risk factors for antepartum stillbirth, including fetal growth restriction, among women with well-dated pregnancies and access to antenatal care.
  
  
  METHODS
  Population-based, prospective, observational study.
  
  
  METHODS
  Eight international urban populations.
  
  
  METHODS
  Pregnant women and their babies enrolled in the Newborn Cross-Sectional Study of the INTERGROWTH-21stProject.
  
  
  METHODS
  Cox proportional hazard models were used to compare risks among antepartum stillborn and liveborn babies.
  
  
  METHODS
  Antepartum stillbirth was defined as any fetal death after 16 weeks' gestation before the onset of labour.
  
  
  RESULTS
  Of 60 121 babies, 553 were stillborn (9.2 per 1000 births), of which 445 were antepartum deaths (7.4 per 1000 births). After adjustment for site, risk factors were low socio-economic status, hazard ratio (HR): 1.6 (95% CI, 1.2-2.1); single marital status, HR 2.0 (95% CI, 1.4-2.8); age ≥40 years, HR 2.2 (95% CI, 1.4-3.7); essential hypertension, HR 4.0 (95% CI, 2.7-5.9); HIV/AIDS, HR 4.3 (95% CI, 2.0-9.1); pre-eclampsia, HR 1.6 (95% CI, 1.1-3.8); multiple pregnancy, HR 3.3 (95% CI, 2.0-5.6); and antepartum haemorrhage, HR 3.3 (95% CI, 2.5-4.5). Birth weight <3rd centile was associated with antepartum stillbirth [HR, 4.6 (95% CI, 3.4-6.2)]. The greatest risk was seen in babies not suspected to have been growth restricted antenatally, with an HR of 5.0 (95% CI, 3.6-7.0). The population-attributable risk of antepartum death associated with small-for-gestational-age neonates diagnosed at birth was 11%.
  
  
  CONCLUSIONS
  Antepartum stillbirth is a complex syndrome associated with several risk factors. Although small babies are at higher risk, current growth restriction detection strategies only modestly reduced the rate of stillbirth.
  
  
  CONCLUSIONS
  International stillbirth study finds individual risks poor predictors of death but combinations promising.
authors.affiliation: Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK.
authors.forename: J E
authors.initials: JE
authors.lastname: Hirst
authors.affiliation: Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK.
authors.forename: J
authors.initials: J
authors.lastname: Villar
authors.affiliation: Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotas, Pelotas, Brazil.
authors.forename: C G
authors.initials: CG
authors.lastname: Victora
authors.affiliation: Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK.
authors.forename: A T
authors.initials: AT
authors.lastname: Papageorghiou
authors.affiliation: Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK.
authors.forename: D
authors.initials: D
authors.lastname: Finkton
authors.affiliation: Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotas, Pelotas, Brazil.|Programa de Pós-Graduação em Saúde e Comportamento, Universidade Católica de Pelotas, Pelotas, RS, Brazil.
authors.forename: F C
authors.initials: FC
authors.lastname: Barros
authors.affiliation: Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), Seattle, WA, USA.
authors.forename: M G
authors.initials: MG
authors.lastname: Gravett
authors.affiliation: Dipartimento di Scienze della Sanità Pubblica e Pediatriche, Università degli Studi di Torino, Torino, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Giuliani
authors.affiliation: Nagpur INTERGROWTH-21st Research Centre, Ketkar Hospital, Nagpur, India.
authors.forename: M
authors.initials: M
authors.lastname: Purwar
authors.affiliation: Center for Perinatal Studies, Swedish Medical Center, Seattle, WA, USA.
authors.forename: I O
authors.initials: IO
authors.lastname: Frederick
authors.affiliation: School of Public Health, Peking University, Beijing, China.
authors.forename: R
authors.initials: R
authors.lastname: Pang
authors.affiliation: Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK.
authors.forename: L
authors.initials: L
authors.lastname: Cheikh Ismail
authors.affiliation: Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK.
authors.forename: A
authors.initials: A
authors.lastname: Lambert
authors.affiliation: Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya.
authors.forename: W
authors.initials: W
authors.lastname: Stones
authors.affiliation: Department of Family & Community Health, Ministry of Health, Muscat, Oman.
authors.forename: Y A
authors.initials: YA
authors.lastname: Jaffer
authors.affiliation: Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK.
authors.forename: D G
authors.initials: DG
authors.lastname: Altman
authors.affiliation: Department of Engineering Science, University of Oxford, Oxford, UK.
authors.forename: J A
authors.initials: JA
authors.lastname: Noble
authors.affiliation: Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK.|Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK.
authors.forename: E O
authors.initials: EO
authors.lastname: Ohuma
authors.affiliation: Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK.
authors.forename: S H
authors.initials: SH
authors.lastname: Kennedy
authors.affiliation: Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.|Center for Global Health for Sick Children, Toronto, ON, Canada.
authors.forename: Z A
authors.initials: ZA
authors.lastname: Bhutta
mesh_terms: D003430:Cross-Sectional Studies; D005260:Female; D005317:Fetal Growth Retardation / Q000453:epidemiology / Q000209:etiology; D020567:Fetal Weight; D005865:Gestational Age; D006801:Humans; D007231:Infant, Newborn; D011247:Pregnancy; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D050497:Stillbirth / Q000453:epidemiology*; D013577:Syndrome
keywords: Antepartum stillbirth; INTERGROWTH-21st; birth weight; fetal growth restriction