CHAPTER ONE

INTRODUCTION

1. BACKGROUND OF STUDY

Stillbirth, defined by the World Health Organization as a baby born with no signs of life at or after 28 weeks gestation, is one of the most common adverse outcomes of pregnancy, yet among the least studied. Every year about 2.6 million stillbirths occur, especially in low-resource countries. Nigeria, with a stillbirth rate of 41.7 per 1000 births, accounts for one of the highest rates in the African continent. Stillbirth rates remain nearly 10 times higher in low–middle-income countries than high-income countries. Stillbirth rates are particularly high in low-income countries because of many factors associated with poverty, such as poor access to basic obstetric care, lack of skilled birth attendants, and high burden of infectious morbidities. Available figures quoted for stillbirth rates across Nigeria reveal the magnitude of this problem. Unfortunately, stillbirths are not seen in this light. This attitude, coupled with ignorance, poverty, and negative socio cultural and faith beliefs are a major impediment to stillbirth prevention.

Stillbirth rates are very important indicators of the quality of obstetric care available in any setting.  In Nigeria, “stillbirths” are still missing in our national systems for vital registration. Lack of a well-defined program agenda, coupled with the lack of data, and social invisibility, deter action and investments for stillbirth prevention and reduction. It is against this backdrop that we undertook this study to estimate stillbirth rate and describe maternal and obstetric characteristics of stillbirths at the Federal Teaching Hospital, Abakaliki (FETHA), southeast Nigeria. The findings derived from this study are crucial in understanding the distribution and pattern of sociodemographic factors of stillbirth in a resource-poor setting like ours.

The birth of a newborn after twenty-eight completed weeks of gestation weighing 1,000 gm or more, with baby showing no signs of life after delivery is a still born’’.  Such death includes both antepartum and intrapartum death. Stillbirths (SB) are the largest contributor to perinatal mortality. Globally, over 3 million babies are stillborn every year with the vast majority occurring in developing countries, while less frequent in developed countries (1%of births), the large contribution of stillbirth to overall perinatal deaths combined with static or increasing rates over the past decade clearly demonstrates that stillbirth is a major public health problem in these settings. In reviewing the research on stillbirth in developing countries, it becomes clear that because almost half of the deliveries in these settings occur at home, under-reporting of stillbirths is a problem, and reliable data about rates and causes are unavailable in some areas of the world.

Nevertheless, of the estimated 3 million stillbirths which occur yearly, the vast majority are in developing countries, with rates in many developing countries ten-fold higher than elsewhere. Despite the large number of stillbirths worldwide, the topic of stillbirths in developing countries has received very little research, programmatic or policy attention. A stillbirth is emotionally upsetting to the parents who are now anxious about the chances of having a pregnancy to carry through successfully in the next confinement. From available data, prolonged and obstructed labor, and various infections all without adequate treatment, appear to account for the majority of stillbirths in developing countries.  This study is an endeavour to find out the causes of still birth in rural referral hospital in Saki Saki west local government.

Worldwide, it was estimated that in 2015 there were 2.6 million third trimester stillbirths (SB) of which 98% occurred in low- and middle-income countries and over three-quarters of these occurring in Sub-Saharan Africa (SSA) and south Asia. It is also estimated that only ten countries carry the burden of over 65% of total stillbirths in the world; Nigeria being ranked in the second position with an estimated 313,700 stillbirths (SB) in 2015. While significant progress was made during the Millennium era in reducing child and maternal mortality, the progress made in reducing stillbirth is the slowest; an annual Average Rate of Reduction (ARR) of 2.0% in comparison to AAR of 3.0% for maternal death or 3.1% for neonatal death. This arose partly from overall neglect of the problem such as poor investment in terms of overseas development assistance that characterized child and maternal health agenda, invisibility of the health problem at both the global and national health agenda despite existence of cost-effective interventions to end preventable stillbirths. However, following the Lancet Series of 2011 and Every Newborn Action Plan (ENAP) of 2014, the issue of stillbirth assumed international health agenda with increased visibility both at national and international health foray. Following these international commitments, a target was set to reduce global (as well as at country level) stillbirth rate of 12 or fewer stillbirths per 1000 births by 2030 from 25 stillbirths per 1000births in 2000. Of the 2.6 million stillbirths estimated to have occurred in 2015, about half, 1.3 million occurred during child birth underscoring the urgent need to provide skilled assistance during this critical period; about 60% of global stillbirths occurred in rural areas.

Risk factors for stillbirths (SB) can broadly be classified into three: maternal, fetal and contextual. Maternal factors include older and younger maternal age; short pregnancy interval, maternal infections (syphilis, malaria in pregnancy), maternal obesity and malnutrition, cigarette smoking, alcohol and drug abuse, maternal disease (pre-eclampsia and eclampsia), previous stillbirth, primiparity and multiparity; fetal factors include male sex, prematurity, extremes of birth weight; while contextual factors include lack of Access to Antenatal Care (ANC), lack of skilled care during child birth, rural residence, low socioeconomic status, type of marriage, ethnicity, poor maternal education and environmental pollution particularly indoor air pollution.

In the Nigerian context, stillbirth is a public health problem where an estimated 313,700 occurred in 2015 making Nigeria the second largest contributor of stillbirths worldwide (12% of the global burden of stillbirth) or 30% of total stillbirths in sub-Saharan Africa. This figure translates to a stillbirth rate of 42.9 per 1000 births. There was an estimated 278,000 stillbirths in 2000 equivalent to a stillbirth rate of 52.3 per 1000, implying an average annual rate of reduction of 1.3%. However, from fragmentary and hospital-based studies, the stillbirth rates as high as 85 per 1000 births have been reported. While Fawole (2011) reported a relatively lower figure of 71 per 1000 births. Though, these studies provide insights into the levels, possible trends and associated factors, they are limited to the areas/hospitals where they have been conducted. Thus, there is a need to estimate a nationally-representative figure with large sample size and more recent data; this was accomplished in the 2013 Nigeria Demographic and Healthy Survey. Still, the DHS final report only provided trends in stillbirth rates against some background socio-demographic characteristics; it is therefore pertinent that a further analysis of the determinants be carried for programming and policy formulation.

The death of a baby to stillbirth is a tragic event for mothers, fathers, siblings and the wider family. Researchers and clinicians studying the psychological outcomes after stillbirth illuminate the emotional and health risks to which stillbirth gives rise. Some research focuses more on the social environment and support, role identity and aspects associated with disenfranchised grief. Other studies, though fewer, have explored the economic cost to stillbirth, one that includes a person’s potential lifetime contribution to the economy. Fox et al. for example, found a conservative annual burden of child death to be 1.6 billion in the U.S. alone while Malacrida4 noted a macro-economic cost of perinatal death to society. This was not through lost labor and productivity but because the lack of societal recognition assigned to perinatal death incites maternal vulnerability to mental, emotional, and social health risks that eventuate to global financial burden.

Perinatal mortality (PM) includes foetal death from 22 weeks of gestation (stillbirth) and death within the first week after live birth (early neonatal death). PM reflects the effectiveness of healthcare provided to mothers and their babies during the antepartum, intrapartum and postpartum periods. It remains a significant global public health issue, particularly in developing countries, where approximately 98% of perinatal deaths occur. A recent global estimate on childhood mortality suggested that approximately 4.8 million perinatal deaths occurred in 2009; of these deaths, 2.6 million were stillbirths while the remainder were early neonatal deaths. These deaths are mostly linked to intrapartum-related stillbirths or newborn deaths; for example, nearly 50% of the 2.6 million stillbirths worldwide occurred in the intrapartum period. Perinatal deaths are preventable with optimal healthcare services, such as adequate receipt of antenatal care during pregnancy, skilled healthcare personnel assistance during labour and delivery, as well as quality care during the postpartum period.

Stillbirths and early neonatal deaths remain unacceptably high in Nigeria. Nigeria currently ranks second globally with nearly half a million stillbirths and third with approximately a quarter million neonatal deaths (0–27 days). Every year in Nigeria, over 75% of neonatal deaths occur during the early neonatal period (0–6 days). The 2013 Nigeria Demographic and Health Survey (NDHS) report on childhood mortality indicated a reversal in gains made over previous years in reduction of perinatal mortality rates (PMRs) from 39 to 41 perinatal deaths per 1000 births between 2008 and 2013, indicating a slight increase by 5.1%. Considering this statistic, the Federal Ministry of Health formulated and adopted the Nigeria Every Newborn Action Plan, whose core aims include a strategic plan to significantly reduce preventable newborn deaths and stillbirths in Nigeria by 2030. This policy initiative lacks comprehensive information on effective ways to treat the health risks experienced by mothers and newborns, such as antepartum bleeding, foetal growth retardation and preterm birth, particularly at the community level where about 66% of births occur at non-healthcare facilities. This is concerning because past studies have shown that antepartum bleeding and foetal growth retardation elevate the risk of PM.

1. STATEMENT OF THE PROBLEM

Few studies on still birth have been conducted in Nigeria, but these studies were all hospital-based with small-scale surveys tailored to fit specific geopolitical populations, the study didn’t capture rural dwellers especially who are most ignorant of the causes of still birth. These studies indicated that low birth weight, maternal age, low number of antenatal visits, ante partum hemorrhage, prolonged labour, caesarean delivery, multiple gestation, unbooked pregnancies and birth asphyxia were associated with prenatal deaths. Limitations of these studies are that stillbirths and early neonatal deaths that occurred at non-healthcare facilities were not included and their findings may not be generalized to the wider Nigerian rural population who are at disadvantaged of proper and well equipped health facilities.

Secondly, environmental factors were not considered in these studies despite the reported relationship between stillbirths and indoor air pollution in earlier studies. Prior to this study, there were no population-based studies assessing still birth or population-attributable risk (PAR) estimates adjusted for independent risk factors related to still birth in Nigeria rural areas.

1. AIMS AND OBJECTIVES

The main aim and objective of this research is to examine the causes of still birth among rural dwellers in Saki Saki Local Government. Other objectives of this study include:

1. to examine the causes of still birth among rural dwellers in Saki Saki Local Government.
2. to examine whether the expectant mothers in Saki saki west are aware of the causes of stillbirth
3. to determine the effect of stillbirth on the women of Saki saki west
4. to examine possible solutions to the causes of still birth in Saki Saki Local Government.
   1. RESEARCH QUESTIONS

1. What are the causes of still birth among rural dwellers in Saki Saki Local Government?
2. Are the expectant mothers in Saki saki west are aware of the causes of stillbirth?
3. What is the effect of stillbirth on the women of Saki saki west?
4. What are the possible solutions to the causes of still birth in Saki Saki Local Government?

1.5 STATEMENT OF RESEARCH HYPOTHESIS

H0: the incidence of stillbirth among rural dwellers in Saki Saki Local Government is high.

H1: the incidence of stillbirth among rural dwellers in Saki Saki Local Government is low.

1. SIGNIFICANCE OF STUDY

Accordingly, this study used national household data, which captured every locality and ethnic group in Nigeria, to investigate the community-, socio-economic-, proximate- (or closest maternal, delivery and newborn characteristics) and environmental-level factors associated with still birth. Most researchers also estimated the adjusted PAR proportions to provide the magnitude of still birth attributable to each significant risk factor in Nigeria.

Estimates from this study will greatly assist health and economic policymakers in formulating cost-effective evidence-based national intervention programs to ensure that existing limited healthcare resources are used appropriately to scale down the rate of still birth across the six geopolitical zones, including rural, metropolitan and urban areas in Nigeria especially in Saki Saki Lcal Government.

1. SCOPE OF STUDY

The study covers the causes of still birth among rural dwellers in Saki Saki Local Government.

1. LIMITATION OF STUDY

Financial constraint- Insufficient fund tends to impede the efficiency of the researcher in sourcing for the relevant materials, literature or information and in the process of data collection (internet, questionnaire and interview).

Time constraint- The researcher will simultaneously engage in this study with other academic work. This consequently will cut down on the time devoted for the research work.

1. DEFINITION OF TERMS

Causes: a person or thing that gives rise to an action, phenomenon, or condition

Still birth: Stillbirth is typically defined as fetal death at or after 20 to 28 weeks of pregnancy (depending on the source). It results in a baby born without signs of life

Rural dwellers: these are people who dwell in areas far away from town and do not have access to some social amenities.