Causes of stillbirth in sub-Saharan Africa and South Asia: Findings from Child Health and Mortality Prevention Surveillance, 2016-2023

Abstract

Background Globally, an estimated 1.9 million stillbirths occur annually, yet significant knowledge gaps exist regarding the causes of stillbirths, particularly in high-burden regions. We investigated fetal and maternal conditions causing stillbirths in seven countries throughout sub-Saharan Africa and South Asia and described missed opportunities for prevention.

Methods Child Health and Mortality Prevention Surveillance (CHAMPS) identified stillbirths at sites in Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa. We asked families for consent to conduct minimally invasive tissue sampling (MITS) from December 2016 to December 2023. An expert panel reviewed test results, clinical information, and verbal autopsy data and assigned fetal and maternal conditions leading to stillbirths and identified missed opportunities for prevention.

Findings A cause of death (fetal or maternal condition) was determined for 94% (2342/2492) of stillbirths; the most frequent condition in the fetus was intrauterine hypoxia (75%, 1864/2492) across all sites, resulting from either maternal conditions (49%, 922/1864) or placental causes (33%, 610/1864). Congenital infections were determined to be the cause of 9% (228/2492) of stillbirths, accounting for the highest proportion in South Africa (28%, 87/306). Group B Streptococcus, Escherichia coli, and Enterococcus faecalis were the most common causative pathogens. Congenital birth defects caused 9% (227/2492) overall and were most common in Ethiopia (24%, 134/568). Primary maternal conditions were identified in 72%, most often placental complications (18%, 446/2492) and maternal hypertension (17%, 414/2492). Placental complications were more common in Mali (43%, 92/212) while maternal medical and surgical conditions were most frequently observed in South Africa (40%, 121/306) and Bangladesh (39%, 158/405). Most (72%, 1808/2492) causes of stillbirth were considered preventable, with heterogeneity observed across sites on the recommended prevention strategies.

Interpretation Complications of pregnancy or delivery were responsible for a large majority of stillbirths. Among the fetal conditions identified, infections and congenital defects were the most common. This study identified widespread gaps in antenatal care and obstetric services as the main drivers of stillbirths. However, there was considerable geographic heterogeneity in underlying causes and recommended prevention measures, suggesting that strategies to reduce stillbirths should be informed by local data to be optimally successful.