Causes of stillbirth in sub-Saharan Africa and South Asia: Findings from Child Health and Mortality Prevention Surveillance, 2016–2023
Afruna Rahman, Kyu Han Lee, Shams El Arifeen, Mohammad Zahid Hossain, Atique Iqbal Chowdhury, Muntasir Alam, Afsana Afrin, Ikechukwu Udo Ogbuanu, Solomon Samura, Erick Kaluma, Julius Ojulong, Samba Sow, Adama Mamby Keita, Milagritos D. Tapia, Kiranpreet Kaur Chawla, Karen Kotloff, Shabir A. Madhi, Sana Mahtab, Yasmin Adam, Amy Wise, Ziyaad Dangor, Christopher Mugah, Elizabeth Oele, Richard Omore, Aggrey K. Igunza, Dickens Onyango, Inacio Mandomando, Quique Bassat, Sara Ajanovic, Rosauro Varo, Elisio Xerinda, Nega Assefa, J. Anthony G. Scott, Lola Madrid, Melisachew M. Yeshi, Fikremelekot Temesgen, Lucy Liu, Portia Mutevedzi, Dianna M. Blau, Victor Akelo, Robert F. Breiman, Cynthia G. Whitney, Emily S. Gurley,Background
Globally, an estimated 1.9 million stillbirths occur annually, yet significant knowledge gaps exist regarding the causes of stillbirths, particularly in high-burden regions. We investigated fetal and maternal conditions causing stillbirths in seven countries in sub-Saharan Africa and South Asia and described missed opportunities for prevention.
Methods
Child Health and Mortality Prevention Surveillance (CHAMPS) identified stillbirths at sites in Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa. We asked families for consent to conduct minimally invasive tissue sampling (MITS) from December 2016 to December 2023. An expert panel reviewed test results, clinical information, and verbal autopsy data and assigned fetal and maternal conditions leading to stillbirths and identified missed opportunities for prevention.
Findings
A cause of death (fetal or maternal condition) was determined for 94% (2342/2492) of stillbirths; the most frequent condition in the fetus was intrauterine hypoxia (75%, 1864/2492) across all sites, resulting from either maternal condition (49%, 922/1864) or placental causes (33%, 610/1864). Congenital infections were determined to be the cause of 9% (228/2492) of stillbirths, accounting for the highest proportion in South Africa (31%, 96/306). Group B Streptococcus, Escherichia coli , and Enterococcus faecalis were the most common causative pathogens. Congenital birth defects caused 9% (227/2492) overall and were most common in Ethiopia (24%, 136/568). Primary maternal conditions were identified in 72%, most often placental complications (18%, 446/2492) and maternal hypertension (17%, 414/2492). Complications of placenta, cord and membranes were more common in Mali (43%, 92/212) while maternal medical and surgical conditions were most frequently observed in South Africa (40%, 121/306) and Bangladesh (39%, 158/405). Most (72%, 1808/2492) causes of stillbirth were considered preventable, with heterogeneity observed across sites on the recommended prevention strategies.
Interpretation
Complications of pregnancy or delivery accounted for most stillbirths across all sites, with intrauterine hypoxia identified as the predominant fetal condition highlighting widespread and persistent gaps in the timely identification and management of maternal and placental conditions during antenatal and obstetric care across sites in Africa and South Asia. At the same time, substantial geographic variation in causes and prevention opportunities, including for infections and birth defects, underscored the need for locally tailored strategies. Strengthening facility-based care alongside targeted interventions based on site-specific patterns, will be critical to reducing the stillbirth burden in these high-priority regions.
Funding
The Gates Foundation