Cause of and factors associated with stillbirth: a systematic review of classification systems.

Introduction An estimated 2.6 million stillbirths occur worldwide each year. A standardised classification system setting out possible cause of death and contributing factors is useful to help obtain comparative data across different settings. We undertook a systematic review of stillbirth classification systems to highlight their strengths and weaknesses for practitioners and policymakers Material and methods We conducted a systematic search and review of the literature undertaken to identify classification systems used to aggregate information for stillbirth and perinatal deaths. Narrative synthesis used to compare range and depth of information required to apply the systems, the different categories provided cause of and factors contributing to stillbirth. Results: A total of 118 documents were screened; 31 classification systems were included, of which 6 were designed specifically for stillbirth, 14 for perinatal death, 3 systems include neonatal and 2 include infant deaths. The majority (27/31) were developed in and first tested using data obtained from high-income settings. All systems require information from clinical records. One-third of the classification systems (11/31) include information obtained from histology or autopsy. The percentage where cause of death remained unknown ranged from 0.39% using the Nordic-Baltic classification to 46.4% using the Keeling system. Conclusion Over time, classification systems have become more complex. The success of application is dependent on the availability of detailed clinical information and laboratory investigations. Systems which adopt a layered approach allow for classification of cause of death to a broad as well as to a more detailed level

Board Attributes and Corporate Social Responsibility Performance of Listed Cement Companies in Nigeria

This study examines the impact of board attributes on corporate social responsibility performance of Listed Cement Companies in Nigeria. The data were collected from annual reports and accounts of the sampled companies for the period of twelve years from 2004 to 2014. Data were analyzed by means of descriptive statistics to provide summary statistics for the variables. Ordinary Least Square (OLS) and Generalized Least Square (GLS) regression were used in testing the study hypotheses using STATA software version 12.00. A panel data regression technique is employed since the data has both time series and cross sectional attributes. The study finds that board attributes have significant impact on corporate social responsibility performance in the listed cement companies in Nigeria. Thus, Board size has significant positive impact and managerial ownership has significant negative impact, and board composition have insignificant positive impact on the corporate social responsibility performance. The study concludes that board attributes have a very strong explanatory power on the variations of corporate social responsibility performance in the Nigerian listed cement companies. The study recommends that to promote good relationship with host communities through CSR and its related disclosure, the Nigerian listed cement companies’ owners should ensure competent board sizes are put in place. Any increase in the board size should constitute the increase in the number of non-executive directors. Keyword: Corporate Social Responsibility Performance, board attributes, Nigeria

Stillbirth in low- and middle-income countries: addressing the 'silent epidemic'.

Annually, an estimated 2.6 million stillbirths occur worldwide.1 With five deaths every single minute, stillbirth is the fifth leading global cause of death when compared with causes of death in all age categories—outranking diarrhoea, HIV/AIDS, TB, road traffic accidents and any form of cancer.2 The vast majority (98%) of stillbirths occur in low- and middle-income countries (LMICs). This has also been referred to as the ‘silent epidemic’

Application of the ICD-PM classification system to stillbirth in four sub-Saharan African countries.

OBJECTIVE:To identify the causes and categories of stillbirth using the Application of ICD-10 to Deaths during the Perinatal Period (ICD-PM). METHODS:Prospective, observational study in 12 hospitals across Kenya, Malawi, Sierra Leone and Zimbabwe. Healthcare providers (HCPs) assigned cause of stillbirth following perinatal death audit. Cause of death was classified using the ICD-PM classification system. FINDINGS:1267 stillbirths met the inclusion criteria. The stillbirth rate (per 1000 births) was 20.3 in Malawi (95% CI: 15.0-42.8), 34.7 in Zimbabwe (95% CI: 31.8-39.2), 38.8 in Kenya (95% CI: 33.9-43.3) and 118.1 in Sierra Leone (95% CI: 115.0-121.2). Of the included cases, 532 (42.0%) were antepartum deaths, 643 (50.7%) were intrapartum deaths and 92 cases (7.3%) could not be categorised by time of death. Overall, only 16% of stillbirths could be classified by fetal cause of death. Infection (A2 category) was the most commonly identified cause for antepartum stillbirths (8.6%). Acute intrapartum events (I3) accounted for the largest proportion of intrapartum deaths (31.3%). In contrast, for 76% of stillbirths, an associated maternal condition could be identified. The M1 category (complications of placenta, cord and membranes) was the most common category assigned for antepartum deaths (31.1%), while complications of labour and delivery (M3) accounted for the highest proportion of intrapartum deaths (38.4%). Overall, the proportion of cases for which no fetal or maternal cause could be identified was 32.6% for antepartum deaths, 8.1% for intrapartum deaths and 17.4% for cases with unknown time of death. CONCLUSION:Clinical care and documentation of this care require strengthening. Diagnostic protocols and guidelines should be introduced more widely to obtain better data on cause of death, especially antepartum stillbirths. Revision of ICD-PM should consider an additional category to help accommodate stillbirths with unknown time of death

Quality of stillbirth and neonatal death audit in Malawi: A descriptive observational study

WHO developed a guideline for implementing stillbirth and neonatal death audits at healthcare facilities in 2016. Like many other poor resource countries, stillbirths and neonatal deaths rates remain high in Malawi despite implementation of audit. This paper assesses the quality of facility-based stillbirth and neonatal death audit implementation in Malawian hospitals and provides recommendations for improvement. In accordance with the WHO audit guidelines, we applied mixed methods to determine the quality of audit implementation in seven hospitals in Malawi. We reviewed hospital surveillance data; audit document forms and action plans. We sought staff perceptions and opinions through a questionnaire and interviews and observed audit meetings. Quantitative data was analysed using IBM SPSS 26.0 and presented using frequencies and proportions. Qualitative data were analysed using predefined themes in a survey guide. The frequency of audits and number of stillbirth and neonatal deaths audited varied significantly between hospitals. No hospital had national audit guidelines. Deficiencies included limited information on neonatal death audit data collection and reporting tools, incomplete documentation, lack of senior staff commitment and a blame or shame atmosphere. Audit meetings often did not start with review of ward statistics, previous minutes and follow-up as to whether previous recommendations had been implemented. Challenges in analysing audit information and recommending solutions resulted in lowquality action plans. No objective evidence was found that audit recommendations were implemented. Assessed according to WHO guidelines, audits were of low quality resulting in challenges in identifying and addressing factors contributing to mortality. We recommend regular audit implementation, with completion of audit cycles for audit to contribute to mortality reduction

Resource availability and barriers to delivering quality care for newborns in hospitals in the southern region of Malawi: A multisite observational study

Facility-based births have increased in low and middle-income countries, but babies still die due to poor care. Improving care leads to better newborn outcomes. However, data are lacking on how well facilities are prepared to support. We assessed the availability of human and material resources and barriers to delivering quality care for newborns and barriers to delivering quality care for newborns. We adapted the WHO Service Availability and Readiness Assessment tool to evaluate the resources for delivery and newborn care and barriers to delivering care, in a survey of seven hospitals in southern Malawi between January and February 2020. Data entered into a Microsoft Access database was exported to IBM SPSS 26 and Microsoft Excel for analysis. All hospitals had nursery wards with at least one staff available 24 hours, a clinical officer trained in paediatrics, at least one ambulance, intravenous cannulae, foetal scopes, weighing scales, aminophylline tablets and some basic laboratory tests. However, resources lacking some or all of the time included anticonvulsants, antibiotics, vitamin K, 50% dextrose, oxytocin, basic supplies such as cord clamps and nasal gastric tubes, laboratory tests such as bilirubin and blood culture and newborn clinical management guidelines. Staff reported that the main barriers to providing high-quality care were erratic supplies of power and water, inadequacies in the number of beds/cots, ambulances, drugs and supplies, essential laboratory tests, absence of newborn clinical protocols, and inadequate staff, including paediatric specialists, in-service training, and support from the management team. In hospitals in Malawi, quality care for deliveries and newborns was compromised by inadequacies in many human and material resources. Addressing these deficiencies would be expected to lead to better newborn outcomes

Prospective study to explore changes in quality of care and perinatal outcomes after implementation of perinatal death audit in Uganda

Objective To assess the effects of perinatal death (PND) audit on perinatal outcomes in a tertiary hospital in Kampala. Design Interrupted time series (ITS) analysis. Setting Nsambya Hospital, Uganda. Participants Live births and stillbirths. Interventions PND audit. Primary and secondary outcome measures Primary outcomes: perinatal mortality rate, stillbirth rate, early neonatal mortality rate. Secondary outcomes: case fatality rates (CFR) for asphyxia, complications of prematurity and neonatal sepsis. Results 526 PNDs were audited: 142 (27.0%) fresh stillbirths, 125 (23.8%) macerated stillbirths and 259 (49.2%) early neonatal deaths. The ITS analysis showed a decrease in perinatal death (PND) rates without the introduction of PND audits (incidence risk ratio (IRR) (95% CI) for time=0.94, p<0.001), but an increase in PND (IRR (95% CI)=1.17 (1.0 to –1.34), p=0.0021) following the intervention. However, when overdispersion was included in the model, there were no statistically significant differences in PND with or without the intervention (p=0.06 and p=0.44, respectively). Stillbirth rates exhibited a similar pattern. By contrast, early neonatal death rates showed an overall upward trend without the intervention (IRR (95% CI)=1.09 (1.01 to 1.17), p=0.01), but a decrease following the introduction of the PND audits (IRR (95% CI)=0.35 (0.22 to 0.56), p<0.001), when overdispersion was included. The CFR for prematurity showed a downward trend over time (IRR (95% CI)=0.94 (0.88 to 0.99), p=0.04) but not for the intervention. With regards CFRs for intrapartum-related hypoxia or infection, no statistically significant effect was detected for either time or the intervention. Conclusion The introduction of PND audit showed no statistically significant effect on perinatal mortality or stillbirth rate, but a significant decrease in early neonatal mortality rate. No effect was detected on CFRs for prematurity, intrapartum-related hypoxia or infections. These findings should encourage more research to assess the effectiveness of PND reviews on perinatal deaths in general, but also on stillbirths and neonatal deaths in particular, in low-resource settings

"We are the ones who should make the decision" - knowledge and understanding of the rights-based approach to maternity care among women and healthcare providers.

BackgroundExperiences and perceptions of poor quality of care is a powerful determinant of utilisation of maternity services. With many reports of disrespect and abuse in healthcare facilities in low-resource settings, women's and healthcare providers' understanding and perception of disrespect and abuse are important in eliminating disrespect and abuse, but these are rarely explored together.MethodsThis was a qualitative study assessing the continuum of maternity care (antenatal, intrapartum and postnatal care) at the Maternity Unit of Bwaila Hospital in Lilongwe, Malawi. Focus group discussions (FGDs) were conducted separately for mothers attending antenatal clinic and those attending postnatal clinic. For women who accessed intrapartum care services, in-depth interviews were used. Participants were recruited purposively. Key informant interviews were conducted with healthcare providers involved in the delivery of maternal and newborn health services. Topic guides were developed based on the seven domains of the Respectful Maternity Care (RMC) Charter. Data was transcribed verbatim, coded and analysed using the thematic framework approach.ResultsA total of 8 focus group discussions and 9 in-depth interviews involving 64 women and 9 key informant interviews with health care providers were conducted. Important themes that emerged included: the importance of a valued patient-provider relationship as determined by a good attitude and method of communication, the need for more education of women regarding the stages of pregnancy and labour, what happens at each stage and which complications could occur, the importance of a woman's involvement in decision-making, the need to maintain confidentiality when required and the problem of insufficient human resources. Prompt and timely service was considered a priority. Neither women accessing maternity care nor trained healthcare providers providing this care were aware of the RMC Charter.ConclusionsThis study has highlighted the most essential aspects of respectful maternity care from the viewpoint of both women accessing maternity care and healthcare providers. Although RMC components are in place, healthcare providers were not aware of them. There is the need to promote the RMC Charter among both women who seek care and healthcare providers

Factors impacting—stillbirth and neonatal death audit in Malawi: a qualitative study

Background: Over one million babies are stillborn or die within the first 28 days of life each year due to preventable causes and poor-quality care in resource-constrained countries. Death audit may be a valuable tool for improving quality of care and decreasing mortality. However, challenges in implementing audit and their subsequent action plans have been reported, with few successfully implemented and sustained. This study aimed to identify factors that affect stillbirth and neonatal death audit at the facility level in the southern region of Malawi. Methods: Thirty-eight semi-structured interviews and seven focus group discussions with death audit committee members were conducted. Thematic analysis was guided by a conceptual framework applied deductively, combined with inductive line-by-line coding to identify additional emerging themes. Results: The factors that affected audit at individual, facility and national level were related to training, staff motivation, power dynamics and autonomy, audit organisation and data support. We found that factors were linked because they informed each other. Inadequate staff training was caused by a lack of financial allocation at the facility level and donor-driven approaches to training at the national level, with training taking place only with support from funders. Staff motivation was affected by the institutional norms of reliance on monetary incentives during meetings, gazetted at the national level so that audits happened only if such incentives were available. This overshadowed other benefits and non-monetary incentives which were not promoted at the facility level. Inadequate resources to support audit were informed by limited facility-level autonomy and decision-making powers which remained controlled at the national level despite decentralisation. Action plan implementation challenges after audit meetings resulted from inadequate support at the facility level and inadequate audit policy and guidelines at the national level. Poor documentation affected audit processes informed by inadequate supervision and promotion of data usage at both facility and national levels. Conclusions: Given that the factors that facilitate or inhibit audits are interconnected, implementers, policymakers and managers need to be aware that addressing barriers is likely to require a whole health systems approach targeting all system levels. This will require behavioural and complex intervention approaches

Stillbirth surveillance and review in rural districts in Bangladesh

Background An estimated 2.6 million stillbirths occur every year, with the majority occurring in low- and middle-income countries. Understanding the cause of and factors associated with stillbirth is important to help inform the design and implementation of interventions aimed at reducing preventable stillbirths. Methods Population-based surveillance with identification of all stillbirths that occurred either at home or in a health facility was introduced in four districts in Bangladesh. Verbal autopsy was conducted for every fifth stillbirth using a structured questionnaire. A hierarchical model was used to assign likely cause of stillbirth. Results Six thousand three hundred thirty-three stillbirths were identified for which 1327 verbal autopsies were conducted. 63.9% were intrapartum stillbirths. The population-based stillbirth rate obtained was 20.4 per 1000 births; 53.9% of all stillbirths occurred at home. 69.6% of mothers had accessed health care in the period leading up to the stillbirth. 48.1% had received care from a highly trained healthcare provider. The three most frequent causes of stillbirth were maternal hypertension or eclampsia (15.2%), antepartum haemorrhage (13.7%) and maternal infections (8.9%). Up to 11.3% of intrapartum stillbirths were caused by hypoxia. However, it was not possible to identify a cause of death with reasonable certainty using information obtained via verbal autopsy in 51.9% of stillbirths. Conclusions Introducing surveillance for stillbirths at community level is possible. However, verbal autopsy yields limited data, and the questionnaire used for this needs to be revised and/or combined with information obtained through case note review. Most women accessed and received care from a qualified healthcare provider. To reduce the number of preventable stillbirths, the quality of antenatal and intrapartum care needs to be improved