Facility-based stillbirth surveillance review and response: an initiative towards reducing stillbirths in a tertiary care hospital of India

Introduction

Worldwide in 2019, nearly 2.0 million babies were stillborns and about half of them occur in six countries and India is one among them [1, 2]. There is substantial variation in stillbirth rates across countries, the highest stillbirth rate reported is 32.3 per 1,000 births whereas the lowest is 1.4 per 1,000 births [2]. The stillbirth rate of India is 13.9 per 1,000 births in 2019 with wide interstate variation [2]. In spite of such a huge burden of stillbirths, global attention towards stillbirth is insufficient and the annual reduction rate for stillbirth is far behind the maternal or under five child mortality rates [1]. The every newborn action plan (ENAP) was endorsed by United Nations to every country to reduce the stillbirth burden and to achieve the stillbirth rate of 12 or fewer per 1,000 births by 2030 [3]. ENAP also recommends improving the perinatal death (stillbirth + neonatal deaths) registration, investigation to assign the cause of death, identification of modifiable risk factors and implementation of high quality national audits. Suboptimal care has been found unacceptably high according to the recent reports from the countries where national perinatal audit programmes have been achieved a reduction in stillbirth rate [3, 4].

Following ENAP, India also set the single digit stillbirth target for 2030 under INAP (Indian newborn action plan), first national stillbirth prevention target [5]. In India, the pilot Stillbirth surveillance was initiated from July 2014; through a joint collaboration between WHO Regional Office for South-East Asia (SEARO) and CDC, USA under the SEAR-NBBD initiative along with newborns birth defect surveillance. A network of hospitals with high delivery load was identified to report stillbirths under the integrated newborn birth defects (NBBD) database, with the aim to establish a National Network of institutions in India. In order to plan further preventive strategies this project was further extended beyond counting numbers, to start auditing each fetal death on the basis of ‘Making Every Baby Count’ recommendations on perinatal audits [6]. Stillbirth review and response is also a type of medical audit, involves the systematic review of each fetal death and to critically analyze the modifiable factors contributing to stillbirth. The primary objective of stillbirth review and response is to improve the quality of patient care, formulate the appropriate actions to address the modifiable factors, implement and achieve the goal of ending preventable stillbirths [7]. This study presents the process of stillbirth audit (review and response) in a tertiary care referral hospital of Northern India and the recommendations made.

Materials and methods

Results

From December 2018 to November 2019, 266 stillbirths delivered out of 5,248 births with a stillbirth rate of 50.6 per 1,000 births. Of these stillbirths 43 (16.2%) occurred before 28 weeks and 223 (83.8%) after 28 weeks, yielding a late stillbirth rate of 42.5 per 1,000 births. These stillbirths were identified from delivery register and verified with nursing officer’s records as per institutional protocol all deliveries occurring in labor room, operation theater, ICUs, HDU or Burn ward are being reported to labor room team and recorded in delivery register and nursing officer’s registers. The demographical and clinical characteristics of stillbirth >28 weeks (n=223) are depicted in Table 1. The minimum perinatal indicators, six essential pieces of information were collected for each stillbirth, includes maternal age, mode of delivery, birth weight, gestational age, birth outcome and place of delivery. Monthly total live births, stillbirths, proportion of antepartum, intrapartum and neonatal death were also collected from labor room register and various rates were calculated for review i.e. stillbirth rate, neonatal mortality rate, intrapartum stillbirth rate, cesarean rate as depicted in Figure 1. The fall in proportion of intrapartum stillbirth over the months was observed during the study period, however it was not statistically significant (p value 0.1107). Table 2 shows the distribution of cause of death of 223 stillbirths according to ICD-PM System of classification. Maternal medical and surgical conditions were the most frequent (55.6%) followed by complications of placenta, cord and membranes (14.7%), maternal complications of pregnancy (9.4%). 65.5% (146/223) of stillbirths were antepartum i.e. fetal death occurred before the onset of labor, rest were intrapartum (34.5%). Antepartum hypoxia (A3=22.4%) and disorders related to fetal growth (A5=20.6%) were the commonest causes of antepartum stillbirths. Among intrapartum the acute intrapartum event (I3=14.8%) and disorder related to fetal growth (I6=10.3%) were the commonest cause assigned.

Figure 1:

Trends of various monthly rates.

The modifiable factors were also compiled separately for antenatal and intrapartum period (Table 3). During antenatal the more frequent factors were no/late antenatal care, no knowledge of danger sign and non availability of delivery facilities during intrapartum period the commonest factors were reached late, delay in referrals and non availability of delivery facilities. Among these antepartum death, 44% women did not have knowledge of danger signs and failed to recognize the seriousness whereas 16% had no antenatal care. Examples of danger signs includes decreased fetal movement, headache (due to increased blood pressure), bleeding per vaginum for which women failed to recognize the seriousness before reaching a health care facility.

Among intrapartum stillbirths, only 4.48% of mother had complications during labour in our study, rest all were attributed to prematurity or low birth weight. Among them 12.9% of families refused for cesarean for fetal indication or neonatal care whereas in 19.5% NICU facilities were unavailable at that point of time (Table 3).

Out of these cases two or three cases were selected for detailed discussion in monthly perinatal meeting. The criteria for selecting cases were mainly where fetal heart was present on admission or who were adequately booked supervised or where different or latest management could have reasonably made the difference in the outcome. Based on monthly perinatal meetings some recommendations were made and few of them were implemented as depicted in Table 4. Some of the changes in practices were as follows: (i) actively enquiring for pruritus to rule out cholestasis of pregnancy and considering early delivery in case of high fasting bile acids; (ii) performing ultrasound at around 34–36 weeks of gestation so as not to miss any fetal growth restriction in busy outpatient departments; (iii) established a triage in emergency area.

Discussion

This study shows a prototype of internal audit of the stillbirths delivered in a tertiary care level where not only the cause of fetal death was assigned, but the modifiable factors were also identified to plan the strategies to reduce the stillbirths further. The main objective of medical audits is improving the patient care, regular review of work and look for latest evidence based management for better outcome.

The important component of stillbirth audit is to assign the most appropriate cause of fetal death. Number of classifications have been recommended and tried in various settings, recently WHO have come up with ICD-PM System of classification [9]. This global system of classification is expected to facilitate the direct comparison irrespective of the settings. Based on the classification system (Table 1), majority of deaths were occurred in antepartum period which signifies the quality of antenatal care. Among antepartum, fetal death related to growth disorders were maximum (46/146–31.5%) which further emphasizes the need of screening of FGR. It also highlights the quality of antenatal care being provided to our women.

In this study 34.5% of women had live fetus at the start of labour and had stillbirth during labour i.e. intrapartum stillbirth. Intrapartum deaths are those deaths which have occurred during labor irrespective of place of death. Globally 50% of stillbirths are intrapartum and the key area of prevention is quality intrapartum care [11]. If we look at the trends of intrapartum stillbirth over a year, there was a fall in proportion of intrapartum stillbirths (Figure 1) which can be considered as the impact of stillbirth audits and change in practice over the time. Similar reduction in intrapartum deaths have also been seen following national audits of high resources settings which reflects the improvement in quality of intrapartum care provided [7]. On further details, only a small proportion (4.48%) of mothers had complications during labour in our study, rest all were attributed to prematurity or low birth weight. So along with quality intrapartum care, there is need to strengthen the neonatal services further to reduce these stillbirths in our settings.

In index study “avoidable” or “missed” opportunities were identified during audits in almost all the cases which might have made the difference in the outcome. On the contrary in national audits of high resource settings, avoidable factors do exist to half of the reviewed cases [7].

In our local audit the area of improvement identified include the quality of antenatal care, fetal growth restriction detection and screening, strengthening referral system, strengthening neonatal intensive care units and delivery facilities for preterm and low birth weight babies and improving the communication and skills of health care providers and increase the awareness of women in pregnancy.

These avoidable factors identified seems to be doable even at resource constrain setting to achieve the target of single digit stillbirth rate [12]. With such a huge burden, India definitely require national audits and new practice guidelines for prevention at large scale however local audits also gives an insight to each individual to work better. LMICS can also learn and implement the interventions from the existing evidence from the achievements of HMICs in reducing our stillbirth burden further [13], [14], [15].

The limitation of this study is that we have not included the deaths occurring in the first neonatal week. We have also not correlated the placental pathology with each cause. Audit system is a time consuming and numbers of professionals are involved in managing these women as most of the cases in our study were referrals. So as such there is no external validation as we have evaluated associated factors from the referrals and enquired from patients and her families only.

Conclusions

This study demonstrates the feasibility of auditing stillbirths at facility level of a huge burden setting. It seems possible to implement the recommendations at local level which can further be used to plan intervention at regional level for reducing the preventable stillbirths further.