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Item Stillbirth 2010-2018: a prospective, population-based, multi-country study from the Global Network(Springer Nature, 2020-11-30) McClure, Elizabeth M.; Saleem, Sarah; Goudar, Shivaprasad S.; Garces, Ana; Whitworth, Ryan; Esamai, Fabian; Patel, Archana B.; Sunder Tikmani, Shiyam; Mwenechanya, Musaku; Chomba, Elwyn; Lokangaka, Adrien; Bose, Carl L.; Bucher, Sherri; Liechty, Edward A.; Krebs, Nancy F.; Kumar, S. Yogesh; Derman, Richard J.; Hibberd, Patricia L.; Carlo, Waldemar A.; Moore, Janet L.; Nolen, Tracy L.; Koso-Thomas, Marion; Goldenberg, Robert L.; Pediatrics, School of MedicineBackground: Stillbirth rates are high and represent a substantial proportion of the under-5 mortality in low and middle-income countries (LMIC). In LMIC, where nearly 98% of stillbirths worldwide occur, few population-based studies have documented cause of stillbirths or the trends in rate of stillbirth over time. Methods: We undertook a prospective, population-based multi-country research study of all pregnant women in defined geographic areas across 7 sites in low-resource settings (Kenya, Zambia, Democratic Republic of Congo, India, Pakistan, and Guatemala). Staff collected demographic and health care characteristics with outcomes obtained at delivery. Cause of stillbirth was assigned by algorithm. Results: From 2010 through 2018, 573,148 women were enrolled with delivery data obtained. Of the 552,547 births that reached 500 g or 20 weeks gestation, 15,604 were stillbirths; a rate of 28.2 stillbirths per 1000 births. The stillbirth rates were 19.3 in the Guatemala site, 23.8 in the African sites, and 33.3 in the Asian sites. Specifically, stillbirth rates were highest in the Pakistan site, which also documented a substantial decrease in stillbirth rates over the study period, from 56.0 per 1000 (95% CI 51.0, 61.0) in 2010 to 44.4 per 1000 (95% CI 39.1, 49.7) in 2018. The Nagpur, India site also documented a substantial decrease in stillbirths from 32.5 (95% CI 29.0, 36.1) to 16.9 (95% CI 13.9, 19.9) per 1000 in 2018; however, other sites had only small declines in stillbirth over the same period. Women who were less educated and older as well as those with less access to antenatal care and with vaginal assisted delivery were at increased risk of stillbirth. The major fetal causes of stillbirth were birth asphyxia (44.0% of stillbirths) and infectious causes (22.2%). The maternal conditions that were observed among those with stillbirth were obstructed or prolonged labor, antepartum hemorrhage and maternal infections. Conclusions: Over the study period, stillbirth rates have remained relatively high across all sites. With the exceptions of the Pakistan and Nagpur sites, Global Network sites did not observe substantial changes in their stillbirth rates. Women who were less educated and had less access to antenatal and obstetric care remained at the highest burden of stillbirth.Item Trends and determinants of stillbirth in developing countries: results from the Global Network’s Population-Based Birth Registry(Springer Nature, 2018-06-22) Saleem, Sarah; Tikmani, Shiyam Sunder; McClure, Elizabeth M.; Moore, Janet L.; Azam, Syed Iqbal; Dhaded, Sangappa M.; Goudar, Shivaprasad S.; Garces, Ana; Figueroa, Lester; Marete, Irene; Tenge, Constance; Esamai, Fabian; Patel, Archana B.; Ali, Sumera Aziz; Naqvi, Farnaz; Mwenchanya, Musaku; Chomba, Elwyn; Carlo, Waldemar A.; Derman, Richard J.; Hibberd, Patricia L.; Bucher, Sherri; Liechty, Edward A.; Krebs, Nancy; Hambidge, K. Michael; Wallace, Dennis D.; Koso-Thomas, Marion; Miodovnik, Menachem; Goldenberg, Robert L.; Pediatrics, School of MedicineBackground: Stillbirth rates remain high, especially in low and middle-income countries, where rates are 25 per 1000, ten-fold higher than in high-income countries. The United Nations' Every Newborn Action Plan has set a goal of 12 stillbirths per 1000 births by 2030 for all countries. Methods: From a population-based pregnancy outcome registry, including data from 2010 to 2016 from two sites each in Africa (Zambia and Kenya) and India (Nagpur and Belagavi), as well as sites in Pakistan and Guatemala, we evaluated the stillbirth rates and rates of annual decline as well as risk factors for 427,111 births of which 12,181 were stillbirths. Results: The mean stillbirth rates for the sites were 21.3 per 1000 births for Africa, 25.3 per 1000 births for India, 56.9 per 1000 births for Pakistan and 19.9 per 1000 births for Guatemala. From 2010 to 2016, across all sites, the mean stillbirth rate declined from 31.7 per 1000 births to 26.4 per 1000 births for an average annual decline of 3.0%. Risk factors for stillbirth were similar across the sites and included maternal age < 20 years and age > 35 years. Compared to parity 1-2, zero parity and parity > 3 were both associated with increased stillbirth risk and compared to women with any prenatal care, women with no prenatal care had significantly increased risk of stillbirth in all sites. Conclusions: At the current rates of decline, stillbirth rates in these sites will not reach the Every Newborn Action Plan goal of 12 per 1000 births by 2030. More attention to the risk factors and treating the causes of stillbirths will be required to reach the Every Newborn Action Plan goal of stillbirth reduction.Item Trends of antenatal care during pregnancy in low- and middle-income countries: Findings from the global network maternal and newborn health registry(Elsevier, 2019) Tikmani, Shiyam Sunder; Ali, Sumera Aziz; Saleem, Sarah; Bann, Carla M.; Mwenechanya, Musaku; Carlo, Waldemar A.; Figueroa, Lester; Garces, Ana L.; Krebs, Nancy F.; Patel, Archana; Hibberd, Patricia L.; Goudar, Shivaprasad S.; Derman, Richard J.; Aziz, Aleha; Marete, Irene; Tenge, Constance; Esamai, Fabian; Liechty, Edward; Bucher, Sherri; Moore, Janet L.; McClure, Elizabeth M.; Goldenberg, Robert L.; Pediatrics, School of MedicineBackground: Antenatal care (ANC) is an important opportunity to diagnose and treat pregnancy-related complications and to deliver interventions aimed at improving health and survival of both mother and the infant. Multiple individual studies and national surveys have assessed antenatal care utilization at a single point in time across different countries, but ANC trends have not often been studied in rural areas of low-middle income countries (LMICs). The objective of this analysis was to study the trends of antenatal care use in LMICs over a seven-year period. Methods: Using a prospective maternal and newborn health registry study, we analyzed data collected from 2011 to 2017 across five countries (Guatemala, India [2 sites], Kenya, Pakistan, and Zambia). Utilization of any ANC along with use of select services, including vitamins/iron, tetanus toxoid vaccine and HIV testing, were assessed. We used a generalized linear regression model to examine the trends of women receiving at least one and at least four antenatal care visits by site and year, controlling for maternal age, education and parity. Results: Between January 2011 and December 2017, 313,663 women were enrolled and included in the analysis. For all six sites, a high proportion of women received at least one ANC visit across this period. Over the years, there was a trend for an increasing proportion of women receiving at least one and at least four ANC visits in all sites, except for Guatemala where a decline in ANC was observed. Regarding utilization of specific services, in India almost 100% of women reported receiving tetanus toxoid vaccine, vitamins/iron supplementation and HIV testing services for all study years. In Kenya, a small increase in the proportion of women receiving tetanus toxoid vaccine was observed, while for Zambia, tetanus toxoid use declined from 97% in 2011 to 89% in 2017. No trends for tetanus toxoid use were observed for Pakistan and Guatemala. Across all countries an increasing trend was observed for use of vitamins/iron and HIV testing. However, HIV testing remained very low (<0.1%) for Pakistan. Conclusion: In a range of LMICs, from 2011 to 2017 nearly all women received at least one ANC visit, and a significant increase in the proportion of women who received at least four ANC visits was observed across all sites except Guatemala. Moreover, there were variations regarding the utilization of preventive care services across all sites except for India where rates were generally high. More research is required to understand the quality and influences of ANC.