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BMC Pregnancy and Childbirth
Published in: BMC Pregnancy and Childbirth 1/2016

Open Access 01-12-2016 | Research article

Determinants of stillbirths in Ghana: does quality of antenatal care matter?

Author: Patience A. Afulani

Published in: BMC Pregnancy and Childbirth | Issue 1/2016

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Abstract

Background

Each year, over two million babies die before they are born. Like maternal deaths, the great majority of these stillbirths occur in developing countries, with about a third of all cases worldwide in sub-Saharan Africa (SSA). Few studies have, however, examined the determinants of stillbirths in SSA. In addition, the emphases on promoting deliveries by skilled birth attendants and/or in health facilities to prevent maternal deaths, though important, may have undermined efforts to provide good quality antenatal care (ANC), which may have an additional role in preventing stillbirths. This study examines the factors associated with stillbirths in Ghana, focusing on the role of ANC quality.

Methods

Data are from the Ghana Maternal Health Survey (N = 4,868)—a national survey of women of reproductive age. The main analysis includes women who had a pregnancy ending in a live birth or stillbirth in the five years preceding the survey and who received ANC at least once. ANC quality is measured by an index based on receipt (or otherwise) of nine antenatal services during the last pregnancy, including education about pregnancy complications; with receipt of at least of eight services classified as higher quality ANC. Stillbirths refer to babies born dead at seven or more months of pregnancy. Analytic techniques include multilevel logistic regression, with moderation and mediation analysis to examine conditional and intervening effects respectively.

Results

Higher quality ANC decreases the odds of a stillbirth by almost half after accounting for other factors, including the type of delivery provider and facility. Educating pregnant women about pregnancy complications contributes significantly to this difference by ANC quality. The type of delivery facility and provider account for a small proportion (14 %) of the ANC quality effect on stillbirths and a larger proportion of the rural/urban difference (27 %) in stillbirths. Completing the recommended four antenatal visits decreases the odds of a stillbirth. Having a pregnancy complication, a multiple gestation, a past stillbirth, or a sister who died from pregnancy complications increases the odds of a stillbirth.

Conclusions

Good quality ANC can improve birth outcomes in two ways: directly through preventative measures, and indirectly through promoting deliveries in health facilities where complications can be better managed. Targeted programs and policies to increase ANC quality, including adequately educating women on pregnancy complications, will help improve birth outcomes in Ghana, and in SSA as a whole.
Appendix
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Literature
1.
Cousens S, Blencowe H, Stanton C, Chou D, Ahmed S, Steinhardt L, Creanga AA, Tunçalp O, Balsara ZP, Gupta S, Say L, Lawn JE. National, regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. Lancet. 2011;377:1319–30.CrossRefPubMed
2.
Lawn JE, Yakoob MY, Haws RA, Soomro T, Darmstadt GL, Bhutta ZA. 3.2 million stillbirths: epidemiology and overview of the evidence review. BMC Pregnancy Childbirth. 2009;9 Suppl 1:S2.CrossRefPubMedPubMedCentral
3.
Lawn JE, Blencowe H, Pattinson R, Cousens S, Kumar R, Ibiebele I, Gardosi J, Day LT, Stanton C. Stillbirths: Where? When? Why? How to make the data count? Lancet. 2011;377:1448–63.CrossRefPubMed
4.
Lawn JE, Lee ACC, Kinney M, Sibley L, Carlo WA, Paul VK, Pattinson R, Darmstadt GL. Two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done? Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2009;107 Suppl 1:S5–18. S19.CrossRef
5.
Hunfeld JA, Wladimiroff JW, Passchier J, Uniken Venema-van Uden M, Frets PG, Verhage F. Reliability and validity of the Perinatal Grief Scale for women who experienced late pregnancy loss. Br J Med Psychol. 1993;66(Pt 3):295–8.CrossRefPubMed
6.
Di Mario S, Say L, Lincetto O. Risk factors for stillbirth in developing countries: a systematic review of the literature. Sex Transm Dis. 2007;34(7 Suppl):S11–21.CrossRefPubMed
7.
Pattinson R, Kerber K, Buchmann E, Friberg IK, Belizan M, Lansky S, Weissman E, Mathai M, Rudan I, Walker N, Lawn JE. Stillbirths: how can health systems deliver for mothers and babies? Lancet. 2011;377:1610–23.CrossRefPubMed
8.
Bhutta ZA, Das JK, Bahl R, Lawn JE, Salam RA, Paul VK, Sankar MJ, Blencowe H, Rizvi A, Chou VB, Walker N. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet. 2014;384(9940):347–70.CrossRefPubMed
9.
Bhutta ZA, Yakoob MY, Lawn JE, Rizvi A, Friberg IK, Weissman E, Buchmann E, Goldenberg RL. Stillbirths: what difference can we make and at what cost? Lancet. 2011;377:1523–38.CrossRefPubMed
10.
Frøen JF, Gordijn SJ, Abdel-Aleem H, Bergsjø P, Betran A, Duke CW, Fauveau V, Flenady V, Hinderaker SG, Hofmeyr GJ, Jokhio AH, Lawn J, Lumbiganon P, Merialdi M, Pattinson R, Shankar A. Making stillbirths count, making numbers talk - Issues in data collection for stillbirths. BMC Pregnancy Childbirth. 2009;9:58.CrossRefPubMedPubMedCentral
11.
Goldenberg RL, McClure EM, Bann CM. The relationship of intrapartum and antepartum stillbirth rates to measures of obstetric care in developed and developing countries. Acta Obstet. Gynecol. Scand. 2007;86:1303–9. 
12.
13.
Ghana Statistical Service, Ghana Health Service, Macro International. Ghana Maternal Health Survey 2007. 2009.
14.
Ghana Statistical Service (GSS), Ghana Health Service (GHS), ICF Macro. Ghana Demographic and Health Survey 2008. 2009.
15.
Chalumeau M, Bouvier-Colle M-H, Breart G. Can clinical risk factors for late stillbirth in West Africa be detected during antenatal care or only during labour? Int J Epidemiol. 2002;31:661–8.CrossRefPubMed
16.
Engmann C, Walega P, Aborigo RA, Adongo P, Moyer CA, Lavasani L, Williams J, Bose C, Binka F, Hodgson A. Stillbirths and early neonatal mortality in rural Northern Ghana. Trop Med Int Health TM IH. 2012;17:272–82.PubMed
17.
Ha YP, Hurt LS, Tawiah-Agyemang C, Kirkwood BR, Edmond KM. Effect of socioeconomic deprivation and health service utilisation on antepartum and intrapartum stillbirth: population cohort study from rural Ghana. PLoS One. 2012;7:e39050.CrossRefPubMedPubMedCentral
18.
Dassah ET, Odoi AT, Opoku BK. Stillbirths and very low Apgar scores among vaginal births in a tertiary hospital in Ghana: a retrospective cross-sectional analysis. BMC Pregnancy Childbirth. 2014;14:289.CrossRefPubMedPubMedCentral
19.
Yatich NJ, Funkhouser E, Ehiri JE, Agbenyega T, Stiles JK, Rayner JC, Turpin A, Ellis WO, Jiang Y, Williams JH, Afriyie-Gwayu E, Phillips T, Jolly PE. Malaria, intestinal helminths and other risk factors for stillbirth in Ghana. Infect Dis Obstet Gynecol. 2010;2010:350763.CrossRefPubMedPubMedCentral
20.
Donabedian A. The quality of care. How can it be assessed? JAMA J Am Med Assoc. 1988;260:1743–8.CrossRef
21.
22.
WHO. WHO antenatal care randomized trial. Manual for the implementation of the new model. 2002.
23.
Ministry of Health/Ghana Health Service, Reproductive and Child Health Unit. Maternal health record book. 2002.
24.
Edmond KM, Quigley MA, Zandoh C, Danso S, Hurt C, Owusu Agyei S, Kirkwood BR. Aetiology of stillbirths and neonatal deaths in rural Ghana: implications for health programming in developing countries. Paediatr Perinat Epidemiol. 2008;22:430–7.CrossRefPubMed
25.
Treiman DJ. Quantitative data analysis: doing social research to test ideas. San Francisco: Jossey-Bass; 2009.
26.
Crosby RA, DiClemente, Salazar LF. Research Methods in Health Promotion. San Francisco: Jossey-Bass; 2006.
27.
Hox JJ. Multilevel analysis. London: Routledge Academic; 2010.
28.
Rabe-Hesketh S, Skrondal A. Multilevel and longitudinal modeling using stata, volumes I and II, third edition. 3rd ed. College Station: Stata Press; 2012.
29.
Cai T. Investigation of Ways to Handle Sampling Weights for Multilevel Model Analyses. Sociol Methodol. 2013;43:178–219.CrossRef
30.
Hamilton LC. Statistics with STATA: Version 12. 8th ed. Boston: Cengage Learning; 2012.
31.
Aneshensel CS. Theory-Based Data Analysis for the Social Sciences. 2nd ed. Thousand Oaks: SAGE Publications, Inc; 2013.CrossRef
32.
Mood C. Logistic Regression: Why We Cannot Do What We Think We Can Do, and What We Can Do About It. Eur Sociol Rev. 2010;26:67–82.CrossRef
33.
Kohler U, Karlson KB, Holm A. Comparing coefficients between nested nonlinear probability models. Stata J. 2011;11:420–38.
34.
Asundep NN, Jolly PE, Carson A, Turpin CA, Zhang K, Tameru B. Antenatal care attendance, a surrogate for pregnancy outcome? The case of Kumasi, Ghana. Matern. Child Health J. 2014;18:1085–94.
35.
Bergsjo P, Villar J. Scientific basis for the content of routine antenatal care. II. Power to eliminate or alleviate adverse newborn outcomes; some special conditions and examinations. Acta Obstet Gynecol Scand. 1997;76:15–25.CrossRefPubMed
36.
Villar J, Bergsjo P. Scientific basis for the content of routine antenatal care. I. Philosophy, recent studies, and power to eliminate or alleviate adverse maternal outcomes. Acta Obstet Gynecol Scand. 1997;76:1–14.CrossRefPubMed
37.
World Health Organization, UNICEF. Antenatal care in developing countries. Promises, achievements and missed opportunities. An analysis of trends, levels and differentials, 1990–2001. 2003.
38.
Campbell OM, Graham WJ. Strategies for reducing maternal mortality: getting on with what works. Lancet. 2006;368:1284–99.CrossRefPubMed
39.
Ghana Ministry of Health, Ghana Health Service, United Nations Children’s Fund, United Nations Population Fund, World Health Organization, Averting Maternal Death and Disability Program/Mailman School of Public, et al. National Assessment for Emergency Obstetric and Newborn Care. 2011.
40.
Issah K, Nang-Beifubah A, Opoku CF. Maternal and neonatal survival and mortality in the Upper West Region of Ghana. Int J Gynecol Obstet. 2011;113:208–10.CrossRef
41.
Knight HE, Self A, Kennedy SH. Why are women dying when they reach hospital on time? A systematic review of the “third delay.”. PLoS One. 2013;8:e63846.CrossRefPubMedPubMedCentral
42.
Ghana Health Service. Ghana Health Service 2011 annual report. 2012.
43.
Kinfu Y, Dal Poz MR, Mercer H, Evans DB. The health worker shortage in Africa: are enough physicians and nurses being trained? Bull World Health Organ. 2009;87:225–30.CrossRefPubMedPubMedCentral
44.
Abdullah F, Choo S, Hesse AAJ, Abantanga F, Sory E, Osen H, Ng J, McCord CW, Cherian M, Fleischer-Djoleto C, Perry H. Assessment of surgical and obstetrical care at 10 district hospitals in Ghana using on-site interviews. J Surg Res. 2011;171:461–6.CrossRefPubMed
45.
World Health Organisation, UNFPA, UNICEF, Mailman School of Public Health. Averting Maternal Death and Disability (AMDD): Monitoring Emergency Obstetric Care: A Handbook. Geneva: World Health Organization; 2009.
46.
Gans-Lartey F, O’Brien BA, Gyekye FO, Schopflocher D. The relationship between the use of the partograph and birth outcomes at Korle-Bu teaching hospital. Midwifery. 2013;29:461–7.CrossRefPubMed
47.
McClure EM, Saleem S, Pasha O, Goldenberg RL. Stillbirth in developing countries: a review of causes, risk factors and prevention strategies. J Matern Fetal Neonatal Med. 2009;22:183–90.CrossRefPubMedPubMedCentral
48.
Flenady V, Koopmans L, Middleton P, Frøen JF, Smith GC, Gibbons K, Coory M, Gordon A, Ellwood D, McIntyre HD, Fretts R, Ezzati M. Major risk factors for stillbirth in high-income countries: a systematic review and meta-analysis. Lancet. 2011;377:1331–40.CrossRefPubMed
49.
Guildea ZE, Fone DL, Dunstan FD, Sibert JR, Cartlidge PH. Social deprivation and the causes of stillbirth and infant mortality. Arch Dis Child. 2001;84:307–10.CrossRefPubMedPubMedCentral
50.
Sutan R, Campbell D, Prescott GJ, Smith WCS. The risk factors for unexplained antepartum stillbirths in Scotland, 1994 to 2003. J Perinatol Off J Calif Perinat Assoc. 2010;30:311–8.CrossRef
51.
Flenady V, Middleton P, Smith GC, Duke W, Erwich JJ, Khong TY, Neilson J, Ezzati M, Koopmans L, Ellwood D, Fretts R, Frøen JF. Stillbirths: the way forward in high-income countries. Lancet. 2011;377:1703–17.CrossRefPubMed
52.
Spong CY, Reddy UM, Willinger M. Addressing the complexity of disparities in stillbirths. Lancet. 2011;377:1635–6.CrossRefPubMed
53.
Friberg IK, Kinney MV, Lawn JE, Kerber KJ, Odubanjo MO, Bergh A-M, Walker N, Weissman E, Chopra M, Black RE, Science in Action: Saving the lives of Africa‘s Mothers, Newborns, and Children working group, Axelson H, Cohen B, Coovadia H, Diab R, Nkrumah F. Sub-Saharan Africa’s mothers, newborns, and children: how many lives could be saved with targeted health interventions? PLoS Med. 2010;7:e1000295.
Metadata
Title
Determinants of stillbirths in Ghana: does quality of antenatal care matter?
Author
Patience A. Afulani
Publication date
01-12-2016
Publisher
BioMed Central
Published in
BMC Pregnancy and Childbirth / Issue 1/2016
Electronic ISSN: 1471-2393
DOI
https://doi.org/10.1186/s12884-016-0925-9

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