Prevalence of stillbirth at the Buea Regional Hospital, Fako Division south-west region, Cameroon

Introduction The study investigated the prevalence of stillbirth at the Buea regional hospital, by taking cases of pregnant women who attended antenatal clinic(s) and those who did not attend but had their deliveries at the Buea regional hospital. The study specifically estimated the prevalence of stillbirths; identified possible risk factors associated with stillbirths, and determined whether the number of antenatal clinic visits is related to the occurrence of stillbirths-because during antenatal clinic visits, pregnant women are educated on risk factors of stillbirths such as: preterm deliveries; sex of the stillbirth; history of stillbirth; history of abortion(s); what age group of mothers are more likely to have a stillbirth. Methods The study was a hospital based retrospective study at the maternity in which there were 3577 deliveries registered at the Buea regional hospital dated May 1st, 2014 to April 30th, 2017. With the aid of a checklist data was collected, analysed and presented with the use of tables, pie-charts and bar charts. Results The prevalence of stillbirths was 26‰; possible risk factors associated with stillbirths included: preterm deliveries; women aged 20-29 years; history of abortion(s); a history of stillbirth; sex of stillbirths were more of females than males; and insufficient antenatal clinic attendance (≤1 antenatal clinic attendance) had more stillbirths. Conclusion The study established that stillbirths can occur in any woman of child-bearing age. possible risk factors associated with stillbirths included: preterm deliveries; women aged 20-29 years; history of abortion(s); a history of stillbirth; gender of stillbirths were more of females than males; and insufficient antenatal clinic attendance (≤1 antenatal clinic attendance) had more stillbirths.


Introduction
Stillbirth is defined as "a baby born with no signs of life at or after 28 weeks of gestation" [1]. It is also defined as the delivery of a dead foetus whose birth weight is more than 500g [2]. One hundred years ago, stillbirth rates as high as 50 per 1000 births were common. Now, rates of less than 5 per 1000 are often seen-more than a ten-fold reduction. Many of the interventions that prevent stillbirth, including antenatal care, hospitalization for delivery and caesarean section for foetal distress were introduced in high income countries after [1935][1936][1937][1938][1939][1940]. In high income countries, it is now uncommon for stillbirths to occur at term, or intrapartum. Stillbirth rates in some low and middle income countries, and especially those with low health system coverage and quality, approximate those seen in high income representing an annual rate of 2% [1]. There was an estimated stillbirth rate of 25.5 per 1000 births for developing countries in the year 2000, with sub-Saharan Africa representing the highest rate (32.2 per 1000 births or a total of 889,697), followed by South Asia (31.9 per 1000 or a total of 1,286,231 births, while stillbirths range from 5 per 1000 in rich countries to 32 per 1000 in South Asia and sub-Saharan Africa [4].

Methods
Study design: this study was a hospital based retrospective study.
Records at the maternity unit were studied dated from 1 st May 2014 to 30 th April 2017.
Settings and population: all women who gave birth (both through caesarean section and normal delivery) at the Buea regional hospital.

Selection criteria
Inclusion criteria: all deliveries at the Buea regional hospital within the time frame. Deliveries dated from May 1 st , 2014 to April 30 th , 2017.
Exclusion criteria: transferred cases of deliveries. Incomplete documented files where not assessed.
Sample size and sampling: all delivery files at the Buea regional hospital dated May 1 st , 2014 to April 30 th , 2017. This study was a hospital based retrospective study of records at the maternity unit.
Data collection: the data for this study was collected using a checklist which had two parts; SHEET ONE for the outcome of all deliveries (both caesarean sections and normal delivery) and SHEET TWO for only women who had stillbirth(s). The checklist was divided into rows and columns which had demographic variables, preterm deliveries, term deliveries and post term deliveries, sex of the stillbirth, history of stillbirth, history of abortion and number of ANC's attended.
The data obtained was tallied under the various columns with different colours of ink to indicate the various parameters under each age group. This helped facilitated the interpretation of results, for example: a preterm delivery was indicated in black ink, term deliveries in blue ink, post term deliveries in green ink and stillbirths in red ink.
Ethical consideration: ethical clearance was obtained from the Faculty of Health Sciences (FHS), University of Buea and was presented at the Regional Delegation of Public Health to seek for authorization to collect the research data and it was approved. A copy of the authorization letter was presented to the director of the Buea regional hospital for approval and a letter of permission was obtained from the director as well as from the general supervisor of the Buea regional hospital.
Data analysis: after data was collected, it was entered into a software version where it was checked for its completeness, cleaned and analyzed accordingly. Frequency tables and graphs were used to describe some variables.

Results
Presentation and analysis of data: during the period of study, there were 3577 deliveries at the Buea regional hospital, of which 93 were stillbirths giving a prevalence of 26 per thousands. With respect to age, patients were divided into four groups:< 20years; 20-29years; 30-39years; ≥40years.  Table 3).

Discussion
This study was meant to estimate the prevalence of stillbirths at the in Cameroon [5]. Approximately equals to 25.5 per 1000 births for developing countries in the year 2000 and lower than 32.2 per 1000 births in sub-Saharan Africa in which Cameroon is inclusive [5]. It is equal to the average stillbirth rate in developing countries which has been reported to be 26 per 1000 births [6]. The stillbirth rate was significantly higher as compared to stillbirths of other developed countries such as Sweden which had a stillbirth rate of 3.6 per 1000 births [7]. The stillbirth rate of 26 per 1000 in this study is approximately five times higher than that of 5 per thousand in developed countries [6]. Stillbirths occurred most in pre-term births 56(60.2%), followed by term births 31(33.3%) and lastly 6(6.5%) stillbirths in post-term deliveries. This study is in line with results found in a journal which stipulated that stillbirth rates were high and was predominantly associated with preterm births [8]. Mothers aged between 20-29years recorded the highest rate -57(61.3%), followed by mothers aged 30-39years, 20(21.5%) and trailed by mothers aged ≥40years 3(3.2%). This is in line with results which noted that, after the introduction of routine prenatal diagnosis in McGill populations, women aged 35 years and above had fewer stillbirths as compared to their younger counterparts [9]. Furthermore, 3(3.20%) mothers had a history of stillbirth while 90(96.86%) had no history of stillbirths.
This view is also shared with reports of past induced abortion, and a history of stillbirth are among other factors associated with stillbirths [6]. Also, 7(7.5%) mothers have had an abortion in the past while 86(92.5%) mothers have never had an abortion. This view is also shared with reports stated that other factors associated with stillbirths were severe anaemia, low serum folate concentration, past induced abortion, and a history of stillbirth [6].
Stillbirths occurred more in mothers who had attended fewer antenatal clinic. It occurred more in mothers who attended ≤1 ANC which was 59 stillbirths (63.4%); 2 ANC attendance which was 21 stillbirths (22.6%); 3 ANC after which accounted for 10 stillbirths (10.8%) and those with ≥4 ANC attendance had the least number of 3 stillbirths (3.2%). Furthermore, other reported risk factors for stillbirths were: maternal syphilis, maternal malnutrition; and lack of antenatal care: which improving the use of antenatal care, and nutritional status of the mother could effectively contribute towards reducing the unacceptably high burden of stillbirths in developing countries [10]. Results from this study of 53(57%) stillbirths where were females while 40(43%) were males was probably as a result of the fact that more females were delivered. Same observation was found in a research which was to determine whether the risk of stillbirths was associated with male foetal sex was modified by foetal growth >500g between 28-43weeks of gestation in Scotland between 1980 and 1996. The results concluded that male foetuses were at an increased risk of stillbirths and also there was a significant negative interaction between male and increasing birth weight in term, but not preterm deliveries [11]. Results of this study showed that stillbirths occurred more in mothers who had attended fewer antenatal clinics.
It occurred more in mothers who attended ≤1 ANC which was 59 stillbirths (63.4%), those with 2 ANC attendance which was 21 stillbirths (22.6%); those with 3 ANC attendance recorded 10 stillbirths (10.8%); and those who attended ≥4 ANC had the least number of stillbirths -3(3.2%). In developing countries risk factors of stillbirths were: maternal syphilis, maternal malnutrition; and lack of antenatal care which improving use of antenatal care, nutritional status of the mother could effectively contribute towards reducing the unacceptably high burden of stillbirths. Investigated risk factors associated with stillbirths using personal interviews and medical records abstraction in a hospital-based case control study in Thai Nguyen Province-Vietnam concluded that improved maternal health education and care in all communities may reduce the burden of foetal loss in that province which can be gotten at antenatal clinics [10,12].
Limitation of the study: records were not well organized, making the task of data collection difficult.

Conclusion
It was concluded that, the prevalence of stillbirths was 26 per thousand, possible risk factors associated with stillbirth includes: the gestational age of the baby -prevalent in preterm deliveries; age (20-29years); females are more prone to stillbirths than males; a history of abortion; and insufficient ANC attendance (≤1 ANC attendance) are at high changes of having a stillbirth.

What is known about this topic
• The prevalence of stillbirth; • Possible risk factors associated with the occurrence of stillbirths; • Which areas of the globe have the least or highest occurrence of stillbirths.

What this study adds
• Educates health personnels and researchers about the prevalence of stillbirths; • It also educates health personnels and the population at

Acknowledgments
We are grateful to all who participated in this research.