The antepartum stillbirth syndrome: risk factors and pregnancy conditions identified from the INTERGROWTH-21st Project

IntroductionPreventing stillbirths is a global concern and ongoing challenge. Stillbirths are classified as either antepartum stillbirths (those that occur before birth) or intrapartum stillbirths (those that occur during labour and delivery.  Of the two groups there is a better understanding of intrapartum stillbirths – they are directly related to the quality of care during birth. They can be reduced by improving the quality of care, closer foetal monitoring and access to interventions should they be needed during birth. Antepartum stillbirths however remain less understood, harder to predict and to prevent. Preventing antepartum stillbirths is shown to be more of a challenge due to:

• The link between clinical and pregnancy related conditions and stillbirths is unclear so it is hard to screen for women at increased risk.
• Most reported associations between socio-demographic factors / clinical conditions and antepartum stillbirth have not been strong or transferrable to other populations.
• Challenges remain in determining the association between foetal growth restriction (FGR) and antepartum stillbirth as most FGR cases are diagnosed after birth.

In this paper, the authors present their findings on the Newborn Cross-Sectional Study (NCSS) as part of the Intergrowth-21st Project. For the study, they aimed to explore the risk factors related to antepartum stillbirth by examining foetal-growth and pregnancy outcomes of women whom received ultrasounds and good antenatal care during pregnancy in eight urban settings worldwide, including the Parklands suburb of Nairobi, Kenya. Data was collected between 2009 and 2013. Stillbirth was defined as foetal death between 16 weeks and birth.ResultsRisk factors that were found to be associated with antepartum stillbirth were:

• Low socio-economic status
• Marital status  of single, widowed or divorced
• Hypertension
• HIV/AIDS
• Maternal age over 40
• Pre-eclampsia
• Bleeding in pregnancy
• Multiple pregnancy
• A history of either prenatal loss, preterm delivery or high or low birth weight
• Altered growth or small foetal size on ultrasound

Key findings

• Antepartum stillbirth can be as low as 10 per 1,000 total births where populations have access to “adequate health care, education, nutrition and maternity care”.
• Independently, clinical and demographic factors related to antepartum stillbirth are poor determinants of  antepartum death.
• Less than 10% of antepartum deaths can be prevented by modifying independent risks.

ConclusionWhile small foetuses have a higher risk of stillbirth, present ways of diagnosing growth restriction only marginally reduced stillbirths.The authors state that their results confirm that antepartum stillbirth is a complex syndrome. They suggest combining interventions that target risks, biological markers and growth trends to identify women at risk of stillbirth.To read this article for free, click here.Hirst, J.E., Villar, J., Victoria, C.G., Papageorghiou A.T., Finkton, D., Barros, F.C., Gravett, M.G., Giuliani, F., Purwar, M., Frederik, I.O., Pang, R., Cheikh Ismail, L., Lambert, A., Stones, W., Jaffer, Y.A., Altman, D.G., Noble, J.A., Ohuma, E.O., Kennedy, S.H., Bhutta, Z.A., for the International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st). (2016). The antepartum stillbirth syndrome: risk factors and pregnancy conditions identified from the INTERGROWTH-21st Project. BJOG