Community-based prevention of stillbirths in Nigeria: a mixed methods study
Domain:
healthcareRecord type:
paper
Creator:
Gwa
Editor:
NaiKurOpoMcL
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Background
Each year, 182,000 babies are stillborn in Nigeria, ~10% of the global burden of stillbirths. Most stillbirth prevention in Nigeria has been hospital-focused, but with over 60% of childbirths in Nigeria occurring outside health facilities, community-based prevention strategies could be transformative. There is a dearth of evidence to guide policy and development of such interventions in Nigeria. This thesis aimed to review existing evidence, estimate the incidence and investigate the determinants of antepartum and intrapartum stillbirths in Imo State, and utilise women’s and health workers’ insights to generate evidence-based recommendations for community-based stillbirth prevention in Nigeria.
Methods
A systematic review and meta-analysis were conducted to ascertain the types, completeness of reporting, effects and acceptability of community-based interventions for stillbirth prevention implemented in sub-Saharan Africa. A convergent parallel mixed-methods study consisting of a case-control study and a descriptive qualitative study was conducted in Imo State, Nigeria. Data from 157 antepartum and 193 intrapartum stillbirths and 381 livebirths (controls) were collected from 20 secondary hospitals. Crude stillbirth rates were calculated, and independent multivariable logistic regression models were used to investigate the association of potential risk factors with each stillbirth type. Thirty in-depth interviews and three focus group discussions were conducted with women who had stillbirths and near-misses and health workers. Interview and focus group transcripts were analysed using thematic analysis, with findings organised according to the socioecological model.
Results The interventions identified in the systematic review were: nutritional, infection prevention, improving access to skilled childbirth attendants and health knowledge/behaviour of women. Interventions were generally acceptable; few studies explored women’s perceptions, omitting key constructs like ethicality and the burden of intervention. Interventions combining community and hospital-based approaches significantly reduced the odds by 17%. In the case-control study, 38 out of every 1,000 babies born in the study hospitals were stillborn. The rates of antepartum and intrapartum stillbirths were 16 and 19 per 1,000, respectively. The risk factors independently associated with antepartum stillbirths were nulliparity (adjusted odds ratio (aOR) 1.87; 95%CI 1.04-3.36); preterm birth (aOR 14.29; 6.31-32.38); being referred from another facility (aOR 3.75; 1.96-7.17); unbooked pregnancy (aOR 2.58; 1.37-4.85); and obstetric complications (aOR 4.04; 2.35-6.94). For intrapartum stillbirths, associated factors were preterm birth (aOR 11.28: 4.66-27.24); referral (aOR 2.50; 1.19-5.24); not using a partogram (aOR 2.92; 1.23-6.95) and obstetric complications (aOR 10.71; 5.92-19.37). The qualitative study participants highlighted that factors including woman’s health knowledge, her source of health information, harmful cultural norms, socioeconomic and family context, and inadequacies within the health system exacerbate the risk of stillbirths. They suggested interventions with a dual approach using tailored interventions at the community and hospital levels.
Discussion and conclusion
The factors contributing to stillbirths in Imo State go beyond clinical care. Clinical and service-related risk factors are intertwined with complex sociocultural barriers. To design effective interventions, these nuances must be understood. The findings of the primary research conducted for this thesis align with those of the systematic review, emphasising that combined community and hospital-based interventions are essential. Additionally, interventions and policies for the prevention of stillbirths in Imo State must go beyond a one-size-fits-all approach to focusing on co-creating multifaceted strategies that are context-specific, adaptable and culturally relevant and involve all relevant stakeholders, including women.
Each year, 182,000 babies are stillborn in Nigeria, ~10% of the global burden of stillbirths. Most stillbirth prevention in Nigeria has been hospital-focused, but with over 60% of childbirths in Nigeria occurring outside health facilities, community-based prevention strategies could be transformative. There is a dearth of evidence to guide policy and development of such interventions in Nigeria. This thesis aimed to review existing evidence, estimate the incidence and investigate the determinants of antepartum and intrapartum stillbirths in Imo State, and utilise women’s and health workers’ insights to generate evidence-based recommendations for community-based stillbirth prevention in Nigeria.
Methods
A systematic review and meta-analysis were conducted to ascertain the types, completeness of reporting, effects and acceptability of community-based interventions for stillbirth prevention implemented in sub-Saharan Africa. A convergent parallel mixed-methods study consisting of a case-control study and a descriptive qualitative study was conducted in Imo State, Nigeria. Data from 157 antepartum and 193 intrapartum stillbirths and 381 livebirths (controls) were collected from 20 secondary hospitals. Crude stillbirth rates were calculated, and independent multivariable logistic regression models were used to investigate the association of potential risk factors with each stillbirth type. Thirty in-depth interviews and three focus group discussions were conducted with women who had stillbirths and near-misses and health workers. Interview and focus group transcripts were analysed using thematic analysis, with findings organised according to the socioecological model.
Results The interventions identified in the systematic review were: nutritional, infection prevention, improving access to skilled childbirth attendants and health knowledge/behaviour of women. Interventions were generally acceptable; few studies explored women’s perceptions, omitting key constructs like ethicality and the burden of intervention. Interventions combining community and hospital-based approaches significantly reduced the odds by 17%. In the case-control study, 38 out of every 1,000 babies born in the study hospitals were stillborn. The rates of antepartum and intrapartum stillbirths were 16 and 19 per 1,000, respectively. The risk factors independently associated with antepartum stillbirths were nulliparity (adjusted odds ratio (aOR) 1.87; 95%CI 1.04-3.36); preterm birth (aOR 14.29; 6.31-32.38); being referred from another facility (aOR 3.75; 1.96-7.17); unbooked pregnancy (aOR 2.58; 1.37-4.85); and obstetric complications (aOR 4.04; 2.35-6.94). For intrapartum stillbirths, associated factors were preterm birth (aOR 11.28: 4.66-27.24); referral (aOR 2.50; 1.19-5.24); not using a partogram (aOR 2.92; 1.23-6.95) and obstetric complications (aOR 10.71; 5.92-19.37). The qualitative study participants highlighted that factors including woman’s health knowledge, her source of health information, harmful cultural norms, socioeconomic and family context, and inadequacies within the health system exacerbate the risk of stillbirths. They suggested interventions with a dual approach using tailored interventions at the community and hospital levels.
Discussion and conclusion
The factors contributing to stillbirths in Imo State go beyond clinical care. Clinical and service-related risk factors are intertwined with complex sociocultural barriers. To design effective interventions, these nuances must be understood. The findings of the primary research conducted for this thesis align with those of the systematic review, emphasising that combined community and hospital-based interventions are essential. Additionally, interventions and policies for the prevention of stillbirths in Imo State must go beyond a one-size-fits-all approach to focusing on co-creating multifaceted strategies that are context-specific, adaptable and culturally relevant and involve all relevant stakeholders, including women.
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