Effect of socioeconomic deprivation and health service utilisation on antepartum and intrapartum stillbirth: population cohort study from rural Ghana.

BACKGROUND: No studies have examined the effect of socioeconomic deprivation on antepartum and intrapartum stillbirths in the poorest women in low income countries. METHODOLOGY/ PRINCIPAL FINDINGS: This study used data from a prospective population based surveillance system involving all women of childbearing age and their babies in rural Ghana. The primary objective was to evaluate associations between household wealth and risk of antepartum and intrapartum stillbirth. The secondary objective was to assess whether any differences in risk were mediated by utilisation of health services during pregnancy. Data were analysed using multivariable logistic regression. Random effect models adjusted for clustering of women who delivered more than one infant. There were 80267 babies delivered from 1 July 2003 to 30 September 2008: 77666 live births and 2601 stillbirths. Of the stillbirths 1367 (52.6%) were antepartum, 989 (38.0%) were intrapartum and 245 (9.4%) had no data on the timing of death. 94.8% of the babies born in the study (76129/80267) had complete data on all covariates and outcomes. 36 878 (48.4%) of babies were born to women in the two poorest quintiles and 3697 (4.9%) had no pregnancy care. There was no association between wealth and antepartum stillbirths. There was a marked 'dose response' of increasing risk of intrapartum stillbirth with increasing levels of socioeconomic deprivation (adjOR 1.09 [1.03-1.16] p value 0.002). Women in the poorest two quintiles had greater risk of intrapartum stillbirth (adjOR 1.19 [1.02-1.38] p value 0.023) compared to the richest women. Adjusting for heath service utilisation and other variables did not alter results. CONCLUSIONS/ SIGNIFICANCE: Poor women had a high risk of intrapartum stillbirth and this risk was not influenced by health service utilisation. Health system strengthening is required to meet the needs of poor women in our study population

Determinants of stillbirths in Ghana: does quality of antenatal care matter?

BACKGROUND: Each year, over two million babies die before they are born. Like maternal deaths, the great majority of these stillbirths occur in developing countries, with about a third of all cases worldwide in sub-Saharan Africa (SSA). Few studies have, however, examined the determinants of stillbirths in SSA. In addition, the emphases on promoting deliveries by skilled birth attendants and/or in health facilities to prevent maternal deaths, though important, may have undermined efforts to provide good quality antenatal care (ANC), which may have an additional role in preventing stillbirths. This study examines the factors associated with stillbirths in Ghana, focusing on the role of ANC quality. METHODS: Data are from the Ghana Maternal Health Survey (N = 4,868)—a national survey of women of reproductive age. The main analysis includes women who had a pregnancy ending in a live birth or stillbirth in the five years preceding the survey and who received ANC at least once. ANC quality is measured by an index based on receipt (or otherwise) of nine antenatal services during the last pregnancy, including education about pregnancy complications; with receipt of at least of eight services classified as higher quality ANC. Stillbirths refer to babies born dead at seven or more months of pregnancy. Analytic techniques include multilevel logistic regression, with moderation and mediation analysis to examine conditional and intervening effects respectively. RESULTS: Higher quality ANC decreases the odds of a stillbirth by almost half after accounting for other factors, including the type of delivery provider and facility. Educating pregnant women about pregnancy complications contributes significantly to this difference by ANC quality. The type of delivery facility and provider account for a small proportion (14 %) of the ANC quality effect on stillbirths and a larger proportion of the rural/urban difference (27 %) in stillbirths. Completing the recommended four antenatal visits decreases the odds of a stillbirth. Having a pregnancy complication, a multiple gestation, a past stillbirth, or a sister who died from pregnancy complications increases the odds of a stillbirth. CONCLUSIONS: Good quality ANC can improve birth outcomes in two ways: directly through preventative measures, and indirectly through promoting deliveries in health facilities where complications can be better managed. Targeted programs and policies to increase ANC quality, including adequately educating women on pregnancy complications, will help improve birth outcomes in Ghana, and in SSA as a whole. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s12884-016-0925-9) contains supplementary material, which is available to authorized users