FACTORS INFLUENCING HIGH PREVALENCE OF FRESH STILL BIRTHS IN MBAGATHI COUNTY

Abednego Ongeso 1 , Magdalene Lukorito 2 and Jane Kabo 3 . 1. PhD in Community Health and Development –Reproductive Health (Great Lakes University of Kisumu, Kenya), MSc.N – Maternal and Neonatal Health (Moi University, Kenya), BSc.N (Moi University, Kenya). Lecturer, School of Nursing Sciences University of Nairobi, Box 19676 – 00200 Nairobi. Tel +254720775815. 2. BSc.N (UoN, Kenya). Staff nurse, Gertrude’s Children Hospital, Box 42325 – 00100 Nairobi. Tel +254722670053. 3. PhD candidate UNISA (S. Africa), MSc.N Midwifery & Obstetric Nursing (UoN, Kenya), BSc.N (Aga Khan University, Kenya). Senior instructor, Aga Khan University, Box 39340-00623 Nairobi. Tel +254722591518 ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History


ISSN: 2320-5407
Int. J. Adv. Res. 6(4), 36-48 38 developing recommendations on evidenced based ways of preventing still births among pregnant women giving birth in Mbagathi County Hospital and the country at large. Further the study is important as the findings would be useful in developing training guidelines and policy review for healthcare workers and women of reproductive geared towards prevention of still births.
on incidences of still births and perinatal mortality and their associated factors among pregnant women established that fresh still births were associated with women with low or no antenatal clinic visits and those who had unskilled delivery. In a similar study by Turnbull, Lembalemba, Brad Guffey, Bolton,Moore, Mubiana, Mbewe, Chintu,& Chi, (2011) on causes of stillbirth, neonatal deaths and early childhood deaths in rural Zambia, it was found that, women with poor educational standards, and those of poor economic status were experiencing more incidences of generally still births both macerated and fresh still birth in relation to more educated and high economic status counterparts. In the same study it was found that women of low education status and those of poor economic status are associated with lack of antenatal care visits which could otherwise help in early detection of possible or impending still births.
Flenady et al (2011) in a study on major risk factors for still births in high income countries, found that fresh still births were common among mothers living in urban area, and women who present late for prenatal care and those who had a gestational age of less than 28 weeks and did not receive prenatal care at all. Further, in the study it was found that fresh still births were also common among primigravidas compared to multiparous women especially those who did not receive adequate care due to illegality of the pregnancy. In a similar study by Gordon, Raynes-Greenow, McGeechan, Morris, and Jeffery (2013) on maternal and fetal risk factors for still birth established that maternal medical conditions during pregnancy was linked to still births both macerated and fresh still birth. Such conditions were pre-eclampisa, diabetes, antepartum hemorrhage, and placenta abruption and severe anemia. Others were Road Traffic Accidents, depression, malnutrition and stress related factors. Lawn et al., (2016) risk factors to still birth, found that maternal obesity (body mass index greater than 30, smoking, pre-existing diabetes, and history of mental health problems, antepartum hemorrhage, fetal growth retardation were potential risk to still births. In a study by Carolan and Frankowska (2011) on advanced maternal age and advanced perinatal outcome, maternal overweight and obesity were high ranking maternal risk factors to still births. Further the study established that advanced maternal age (>35 years) and maternal smoking were associated to still births. Other maternal conditions such as pre-eclampisa, obstructed labour and premature rupture of membranes in addition to underlying maternal medical conditions were associated with fresh still births. Pre-existing diabetes and hypertension remained important contributors to stillbirth in such countries.
According to still birth collaborative research network writing group (2011), Social factors affecting pregnant mothers during pregnancy had significant association with still births. Mothers who were experiencing social deprivation, unemployed or their partners lacking reliable source of outcomes were found to have high incidences of 39 still births both fresh and macerated births. Further, Lawn et al., (2011) established that Pregnancies in which the parents were blood relations were not at a significantly increased risk. In addition, Obesity (body mass index ≥30), active as well as passive smoking, lack of antenatal folic acid, and booking after 13 weeks were all associated with an increased risk of stillbirth. The study further established that a history of mental health problems, diabetes, and stillbirth increased the risk. Pre-eclampisa and antepartum hemorrhage were strongly associated with fresh still birth, whereas gestational diabetes mostly associated with macerated still births.

Institutional Related Factors:-
Healthcare institutions were found to play an important role in determining the quality of pregnancy outcome especially maternal and neonatal wellbeing during and after delivery (WHO, 2015). Studies have shown that fresh stillbirths and early neonatal deaths or mortality (ENNM) may suggest problems with the care available during labor and delivery at any given healthcare facility (Ersdal et al., 2013). According to Musafili et al., (2013) numerous hospital based factors are a major contributor to fresh still birth in many countries across the globe. For instance many facilities in many countries are always understaffed, hence have inability to accurately monitor labor progress and conduct quality deliveries (Lee et al., 2011). Similarly, in a study by Flenadi et al., (2011), health facility inaccessibility in terms of distance and costs has a great impact on the delivery outcomes. The study showed that half of pregnant women delivered at home for reasons that included logistical difficulties in accessing clinical care, transportation costs and a lack of adequate health education from healthcare facilities. In such cases many fresh still births occurred due to inaccessibility of quality labor monitoring and delivery under unqualified healthcare providers. Lawn et al., (2011) established that, many still births occured due to poor monitoring of labor in many health facilities that had been occasioned by shortage of staff hence high workload. The study further found that, the high number of pregnant women visiting the facility with acute shortage of healthcare workers was a major contributing factor.
Aminu et al., (2014) in a study to assess causes of and factors associated with stillbirths in low and middle income countries established that poor use of partograph to monitor labor, lack of theatre facilities and shortage of staff were institutional related factors that contributed to fresh still births among pregnant women. In a similar study, Spong et al, (2011), established that, inaccessibility to the health facility, overcrowding, long waiting hours and high cost of delivery services were associated with increased incidences of fresh still births in many facilities. In addition, poor triaging of mothers, especially those who had history of still births, prolonged labor or underlying conditions such as pre-eclampsia and intrauterine growth retardation was another hospital related factor that also contributed to Fresh Still birth occurrence. Turnbull et al. (2011) showed that a large proportion of stillbirths in high-income countries were attributable to risk factors that were fully or partly avoidable in many healthcare facilities. Delay in decision making on whether mother is to deliver normally or through caesarian section was a major contributor to still births. The study recommended immediate Caesarian section to any mother with signs of fetal distress to save the life of the baby. According to Hogue, and Silver, (2011) culturally appropriate preconception care and quality antenatal care that is accessible to all women had the potential to reduce stillbirth rates in high-income countries. Implementation of national perinatal mortality audit program in hospitals and other healthcare facilities aimed at improving the quality of care could substantially reduce stillbirths.

Fetal Factors Contributing To Fresh Still Births:-
Women from disadvantaged populations in many countries across the world continue to have higher stillbirth rates than those living without such disadvantages; fetal conditions have been associated with still births both fresh and macerated among many pregnant women ( A study conducted by Lawn et al., (2016) on risk factors to still births found that, small for gestational age, and twin pregnancy were highly associated with still births especially in cases where there was no adequate monitoring of labor, and inadequate facilities and staff in labor wards. Frøen, Friberg, Lawn, Bhutta, Pattinson, Allanson and Kinney (2016) in their study, reported that prematurity is a major risk factor in fresh still birth. Majority of fresh birth cases were premature deliveries within the facility. Further the study also established that those extremes of birth weight increased the risk for stillbirth. However, there was no association between still births and the baby's gender. In a similar study by Heazell et al., (2016) it was found that still birth was common among preterm and low birth weight babies. The study showed that still births were common in poor maternal nutritional status, absence of 40 antenatal care, and complications during labor. According to Wallis (2013) in a study on maternal and fetal factors associated with still births established that fetal growth restriction (FGR), twin pregnancies, and premature births were associated with Fresh Still Births.
Kidanto et al., (2015), established that the Risk for stillbirth increased in situations where there was fetal distress during delivery, such as uterine rupture placental abruption, cord prolapse and prematurity. Similarly, Gardosi et al., 2012) found out that fetal growth restrictions, low birth weight, prematurity, and fetal distress due to premature rupture of membranes were highly associated with still births. In the same study, it was established that fetal growth restriction was eight times highly associated with still births. This was supported by the fact that growth restrictions delays birth thereby resulting in death prior to delivery.

Methodology:-Study Design
This was an institutional based descriptive cross-sectional study design containing quantitative methods which was conducted to assess the prevalence and risk factors to stillbirth among pregnant women delivering at Mbagathi County Hospital.

Study Site:-
The study was carried out at the post natal wards in Mbagathi County Hospital. The hospital is situated in Kenyatta Golf Course, Daggoretti Division of Nairobi County. The hospital has several departments which include outpatient, Laboratory, Pharmacy, Medical and Surgical wards, Pediatric ward, Gynecological ward, TB department, Eye and dental clinic, Maternity ward, Maternal and Child Health Clinic and comprehensive care unit.
The reproductive health department (Labor and post natal wards) was selected purposively for carrying out the study because all the mothers after delivery were discharged through. The post natal wards are fully manned by qualified, competent, experienced human resource for health of all cadres consisting of several Medical Officers and midwives who form the bulk of primary health providers in all facilities.

Study Population:-
The study population comprised of all mothers who had fresh still births at the facility and on average 24 mothers had still births per month at Mbagathi County Hospital at the time of the study.

Sampling:-Sample size calculation:-
The sample size was determined using Cochran's formula, (Cochran 1977) A Sample size of 42 mothers was recruited for the study.
Sampling Method:-Consecutive sampling method was used to select the study respondents. Any mother who had a fresh still birth at the time of the study and was willing to participate in the study was recruited.

Data Collection Tool:-
Data was collected using researcher administered structured questionnaires. The questionnaires had 4 parts, i.e. demographic characteristics, maternal factors, fetal factors, and hospital related factors contributing to fresh still births.

Pretesting of the Study Tool:-
A pre-test of the tool was done in Pumwani Maternity Hospital. This was to determine the validity and reliability of the tool. Pretesting also helped the researcher to modify the study tool to be able to capture all the information that helped answer the research questions and met the study objective. Ten percent (10%) of the sample size of 42, which was approximately 5 mothers were recruited for pretesting.
Data Management:-All the study respondents were assigned a respondent identification number (RID). All data entered into the study databases was identified and only associated with a RID in password protected files. A double entry system for the 41 data was maintained. All paper research records were secured in a lockable filling cabinet. Data entry, cleaning and validation was performed in order to achieve a clean data. Soft copies of the data collected were password protected Statistical Analysis:-Data entry and statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 23. Descriptive statistics were analyzed where measures of central tendency like mean mode and median was calculated. The results were presented using tables, bar graphs and pie charts.

Ethical Considerations:-Ethical Principles:-
The three ethical principles; Beneficence, Autonomy and Justice were upheld. This research was carried out in accordance with the basic principles defined in Guidance for Good Clinical Practice and the Principles enunciated in the Declaration of Helsinki (Edinburg, October 2000).

Dissemination of findings:-
Research findings were disseminated to the hospital management through a report. The findings were also presented in symposia, conferences and publication in peer reviewed journals.

Results:-Maternal factors:-Demographic Profile for the Study Respondents:-
Of the 40 respondents who participated in the study, majority 22 (55.0%), were aged below 20 years. Similarly, more than two thirds 27 (68.2%), were married.
Regarding level of education, majority 23 (57.5%) had primary education as their highest level of education, with 25 (62.5%), being unemployed as shown in Table 1 below;   Table 2 illustrates various maternal factors that contribute to fresh still births. Majority 22 (55.0%) of the respondents had a history of previous still birth. Regarding Antenatal Clinic (AANC) attendance, a majority 25 (62.5%), had not made any antenatal clinic visits. Among the respondents who made ANC visits (n=15) two thirds had made less than 4 visits. Finally, majority 28 (70.0%), reported that they took alcohol though didn't smoke.

Institutional Related Factors:-
The following institutional factors were checked on daily basis during the data collection period that lasted 10 days. A check list was used and assessment was done daily during the data collection. The findings were as shown in table  3 below. There was a staff shortage as evidenced by very low midwife to patient ratio. The mothers were not triaged in 60% of the cases. Similarly, 80% of the days, partograph was not used to monitor labor. Further, there were no cardiac monitors and Blood Pressure (BP) machines were not adequate in the facility. However, there were availability of fetoscope, resuscitaires and operating theatres.   Discussion:-Maternal factors:-Study findings revealed that majority of the mothers who had fresh still birth, were young, aged below 20 years, had low literacy level and of low socio-economic status. These findings were in agreement with a study by Turnbull et al., (2011) who found that high incidence of fresh still birth was common among young women of low education status and poor economic backgrounds. The study findings were also in agreement with a study by Flenady et al (2011) who found that fresh still births were also common among young teenage girls who were primigravidas compared to older multiparous women especially those who did not receive adequate care due to illegality of the pregnancy.
In the study, it was established that majority of the mothers who had fresh still births had a preterm pregnancies and similar proportion had their membranes ruptured 18 hours prior to labor. Findings of which concurred with a study by Gordon et al., (2013) which established that fresh still births were common among women with prolonged duration of premature rupture of membranes especially in preterm deliveries.
Further, in this study, it was established that two third of the mothers who had still births had medical conditions during pregnancy. The common medical condition was placenta previa and placenta abruptio, followed by severe pre-eclampsia. Others were ante partum hemorrhages, uterine atony, and severe anemia. The findings were in agreement with a study by Lawn et al., (2016) who found that mothers who had certain medical conditions such as placenta previa, antepartum hemorrhage, severe pre-eclampsia and diabetes were likely to have fresh still birth if they were not properly managed or controlled early. The findings were also in agreement with a study by Carolan and Frankowaska (2011) who also found that maternal conditions such as pre-eclampisa, obstructed labor and premature rupture of membranes in addition to underlying maternal medical conditions were associated with fresh still births. Pre-existing diabetes and hypertension remained important contributors to stillbirth in such countries.In this study, it was also found that majority (55%) of the mothers had history of previous still birth either fresh or macerated, findings of which was in agreement with those of Carolan and Frankowaska (2011), who established that previous fresh still births was a predictor of women who were likely to have fresh still births even in future pregnancies and as such, special attention should given to such women.
In so far as ANC attendance is concerned, majority of the respondents had not attended antenatal clinic at all with only slightly over one third attending majority of who had attended less than 4 visits. Further, 85% of them were either smoking or taking alcohol or both. This indicated that fresh still births were common among women with no or minimal ANC visits findings of which were similar to those by a study by Turn bull et al., (2011) which found that fresh still births were common among women who lack of antenatal care visits which could otherwise help in early detection of possible or impending still births as well as women who seek health care at the last minute in their pregnancy, such as during labor.

Fetal Related Factors:-
The study established that majority of the babies had a gestation of less than 37 weeks and hence were born prematurely. This showed that prematurity was associated with Fresh Still Births. These findings were in agreement 47 with a study by Line et al., (2016) who found that risk factors to still births included small for gestational age or children who were born preterm. The findings were also similar to a study by Froen et al., (2016) who established that prematurity was a major contributing factor to fresh still births and that majority of fresh still births were premature deliveries.
Further, in this study, it was also found that, more than three quarters of the fetuses had complications prior to birth. The common complications were mainly potential fetal distress following premature rupture of membranes and intrauterine fetal growth retardation. This demonstrated that fetal complications during pregnancies and fetal distress during labor were associated with fresh still births in cases where mothers were not given proper care. Findings of the study were in agreement with a study by Kidanto et al., (2015) who established that fresh still birth were common among babies who had fetal complications such as intrauterine fetal growth retardation, fetal distress due to premature rupture of membranes and congenital abnormalities. Findings were also similar to a study by Gardosi et al., (2012) who found that fetal growth restrictions, low birth weight, prematurity, and fetal distress due to premature rupture of membranes were highly associated with still births. In the same study, it was established that fetal growth restriction was eight times highly associated with still births. This was mainly found to be likely because the baby is often not delivered immediately, either due to inappropriate delays or because of concerns about neonatal immaturity.

Institutional related factors:-
The study found that there was low midwife to patient ratio hence the members of staff were not adequate to give quality midwifery care to the mothers. In addition, triaging of patients was not adequately done, which was likely to contribute to emergency cases being missed hence increased number of still births. Further, there was low utilization of partograph in monitoring of the pregnant women in labor. Majority of the equipments necessary in maternity were available, however there were no cardiac monitors, the Blood Pressure machines. The study therefore showed that, the facility lacked adequate staff, had low utilization of partograph, inadequate triaging of patients and lack of some necessary equipment for monitoring of very sick patients. The findings were similar to a study by Ersdal et al., (2013) who found out that fresh stillbirths were associated with inadequate care during labor due to lack of adequate members of staff and at delivery at any given healthcare facility lacking the necessary equipment. The findings were also in agreement with a study by Musafili et al., (2013) who found that understaffing, lack of triaging, inability to accurately monitor labor using partograph, lack of facilities and equipments were highly associated with poor delivery outcomes such as fresh still birth or fetal complications at birth such as severe birth asphyxia.

Conclusions:-
Based on the study findings and discussion above, the followings conclusions were drawn 1. Majority of the mothers with fresh still birth were young aged below 20 years, were of low socio-economic status and did not or made less than four ANC visits. They also had, previous history of still birth, had various medical conditions during pregnancy such as placenta previa/ abruption, APH and prolonged premature rupture of membranes before labor. 2. Majority of the babies were born prematurely (gestation less than 37 weeks), had fetal complications or congenital malformations in utero, and or developed severe fetal distress during labor. 3. Institutional factors associated with fresh still births were, low midwife to patient ratio, lack of utilization of partograph, lack of prompt triaging of pregnant mothers and inadequate or lack of vital equipments critical for monitoring mothers in labor.

Recommendations:-
Based on the above conclusion, the followings are the recommendations. 1. Improve uptake of safe motherhood through improving uptake of focused antenatal care among women of reproductive age and pregnant mothers. This can be done by targeting women of reproductive age in colleges, churches, and even during antenatal clinics. 2. Girl child empowerment to achieve gender equality in line with Sustainable Development Goal 5 will help reduce unwanted fetal deaths since they will be able to seek medical care when required. 3. Improve staffing; develop protocol regarding triaging and labor monitoring using partograph and monitor compliance. 4. The hospital to ensure availability and adequacy of equipments required for proper management of women in labor such as cardiac monitors