THE UNIVERSITY OF ZAMBIA
SCHOOL OF NURSING SCIENCES
FACTORS CONTRIBUTING TO FRESH STILLBIRTHS AT LIVINGSTONE CENTRAL HOSPITAL, ZAMBIA
Ruth Zulu NambalaSupervisor: Dr.Concepta Kwaleyela
Co –Supervisor: Ms. Mutinke Zulu
Globally, maternal and new born care is the major focus of discussion in perinatal care and little attention is paid to fresh stillbirths (WHO, 2011). In the face of some progress in the areas of advocacy, policy formulation, monitoring, and research, substantial gaps remain in the data that is needed to track effective coverage of proven interventions for perinatal survival, and hence hampering accountability. There is little impetus to include stillbirths in policies and programmes for the sustainable Development Goals because stillbirth rate reduction is not a target in these goals(The Lancet, 2011).
However, stillbirth has always been a devastating experience for the mother and of concern in clinical practice. A stillbirth is a baby born after the 28th week gestation of pregnancy and has not at any time after being completely expelled breathed or shown any sign of life (Fraser and Cooper, 2003). A stillbirth can either be an intrapartum stillbirth (fresh) or an antepartum stillbirth (macerated). For intrapartum stillbirths, the death-to-delivery period is assumed to be short and the death likely took place during labour (intrapartum death). Macerated stillbirths are conversely supposed to have occurred before labour (antepartum); the death-to delivery interval is longer and the fetus shows skin and soft tissue changes (skin discoloration or darkening, redness, peeling, and breakdown), all of which are absent in fresh stillbirths (Gold, 2014).
This study aims at identifying factors that contribute to high numbers of fresh stillbirths at Livingstone Central Hospital. The chapter will present the background information, statement of the problem, justification of the study, research objectives, research hypothesis, and the conceptual framework upon which the study will be based on.
Every year, 2.7 million stillbirths are recorded worldwide (Froen, 2011). Ninety eight percent of these stillbirths occur in low and middle income countries (LMIC), and half of these happen in the sub-Saharan Africa resulting in a ten-fold disparity in stillbirth rates between high and LMIC (Lancet, 2011). One million or more stillbirths occur in the intrapartum period and are preventable with good obstetric care.
The period surrounding labour and delivery represents the time of highest risk when 45% of all stillbirths takes place(Gold, 2014).Intrapartum stillbirths are thought to be more preventable as they occur during labour, mainly in term pregnancies and generally without foetal abnormalities (Chigbu et al, 2009). According to Lawn et al., (2011),25-67% of still births are largely due to preventable complications such as prolonged labour. The WHO (2005) also reports that complications arising during delivery are the main causes of deaths among nearly all infants who were alive while labour started, but were born dead. The unacceptable number of intrapartum stillbirths globally might be understood as a mutual underpinning between neglect during intrapartum care, lack of information and failure to apply evidence-based obstetric care practices (WHO, 2005). 75% of the stillbirths occur in developing countries especially around the sub-Saharan Africa and the rural families from these areas account for 60% of these deaths. Sub-Saharan Africa’s stillbirth rate is approximately 10 times that of developed countries (29 to 3 per 1000 births) (WHO, 2005).
When women receive good care during childbirth, less than 10% of stillbirths would be expected and only due to unexpected severe complications (WHO, 2005). Identifying, the gaps in the care provided to women in labour is critical in identifying appropriate interventions to reduce intrapartum stillbirths. If improvement in the quality of intrapartum care and effective emergency obstetric interventions are implemented at the facility level, the number of these stillbirths could be prevented.
According to WHO (2018), the majority of stillbirths are preventable, evidenced by regional variations across the world. Intrapartum stillbirths are more likely to be due to events that occur during labour and delivery such as cord prolapsed, birth trauma, intrapartum asphyxia and other specific complications including foetal distress and obstructed labour (Froen, 2011). In a study conducted in England by West Midlands Confidential enquiry into intrapartum related deaths, it was discovered that all cases revealed substandard care in 84% of the deaths: different management of the cases may have resulted in different outcomes suggesting that the stillbirths were regarded to have been potentially preventable (Kramer et al., 2002).
According to Ministry of Health (MOH) (2010), Zambia has promoted measures to prevent stillbirths. The preventative measures undertaken by MOH include coverage of comprehensive obstetric care, where operative measures for complicated deliveries are being introduced; this is the care given to pregnant women who have developed complications that need surgical interventions to serve their lives. A training policy to sponsor and train midwives in maternal and child health care so that every women can have access to skilled birth attendant personnel has been put in place with a view to prevent complications that may lead to stillbirth during labour and delivery. Following these trainings, it was assumed that midwives and doctors would be able to use the latent phase observation chart and the partograph correctly in identifying risk factors promptly, and institute timely interventions and subsequently reduce intrapartum stillbirths. However, despite the preventative measures undertaken by MOH, Zambia has continued to record a high number of stillbirths and has a crude stillbirth rate reported at 21 per 1000 (UNICEF, 2015). The objective of this study, therefore, is to explore factors contributing to intrapartum stillbirths particularly, those related to obstetric care offered to women who come to deliver at LCH.
1.2 Statement of the Problem
Despite many efforts to eliminate intrapartum stillbirths, at international, regional and national levels, the problem of intrapartum stillbirths has continued to escalate. In 2015, there were 2.6 million stillbirths globally, with 1.3 million dying during labour (WHO, 2018). The larger part of these deaths occurred in developing countries like Zambia and the Sub-Saharan Africa. About half of all still births take place in the intrapartum period representing the greatest time of risk (WHO, 2018). Estimated proportions of stillbirths that are intrapartum vary between 10% in developed countries to 59% in low resource countries (WHO, 2018).
The numbers of fresh stillbirths is a thorny issue at (LCH). According to the hospital information management system (HIMS), the hospital recorded an average number of 32 intrapartum stillbirths in the years between 2015 and 2017 (HIMS, 2017) as shown in table 1 below. It is for this reason that this research will specifically focus on identifying factors contributing to high numbers of intrapartum stillbirths at Livingstone Central Hospital.
Table 1: Intrapartum stillbirths at Livingstone Central Hospital
Source: LCH HIMS (2015/ 2017).
1.3 Justification of the Study
Annually, there are 2.7 million stillbirths world wide and 98% of these are in the Sub-Saharan Africa (The Lancet, 2011). Even though stillbirths represent a large proportion of perinatal deaths, factors contributing to still births are poorly understood. This study seeks to identify factors that lead to intrapartum stillbirths. This will help in coming up with interventions that could be targeted at reducing intrapartum stillbirths at (LCH) The findings will significantly help in scaling up health care interventions to improve intrapartum care provided at L.C.H.
1.4 Research Objective
1.4.1 General Objective
To identify factors contributing to intrapartum stillbirths at L.C.H.
1. 4.2 Specific Objectives
To assess the management of women in labour by midwives and Doctors at L.C.H.
To assess availability of resources necessary for the management of women in labour at L.C.H.
1.5 Research Hypothesis
There is an association between the management provided to women and the incidences of intrapartum stillbirths at L.C.H.
1.6 Conceptual Framework
The most comprehensive model for health care evaluation is the Donebedian model (Simbar et al, 2010). The model was presented in 1966, defining three distinct aspects of quality, which include structure, process and outcome (Donabedian, 1997). It describes a holistic approach in assessing quality of care. Structure outlines the attributes of the setting (physical structure, equipment, surgical, medical supplies and staff characteristics) in which care is offered (Jeng, 2008). Process describes the giving and receiving of care, while outcome denotes the effects of care on the health status of individuals and populations. Structure and process may influence outcome either directly or indirectly (Jeng, 2008). These two main dimensions of health care systemwhich may be assessed are the most relevant to evaluate the practices and the quality of intrapartum care (Jeng, 2008). Due to simplicity and flexibility, the model has been generally accepted and used in many studies (WHO, 2004).
Donabedian’s Quality Framework
The study is concerned with factors that contribute to intrapartum stillbirths. It will focus on how women aremanaged and the availability of resources in the labour ward of L.C.H. This model has been chosen to be used in this study because it describes all the important components and elements of the health care delivery system that are essential in quality care.
1.7.2 Independent variables
Availability of resources
Care provided during intrapartum period
Characteristics of care givers
Years in service
Table 2: Variables and Cut off Points
Variable Indicator Cut off point
Knowledge High level of knowledge. Scores of 10-20 on knowledge questions
Scores below 10on knowledge questions
Low level of knowledge Care provided during intrapartum period (use of partograph and latent phase observation charts) Good Accurately entered partograph and latent phase observations charts with a score of 90% while not accurate for scores less than 90%
Poor Availability of resources Always available Score of more that 90% on the checklist by WHO on the standard of an intrapartum setting termed as adequate resources and score less than 90% will be termed as inadequate resources.
Not available. 1.8 Conceptual Definitions
Stillbirth: A baby born after the 28th week gestation of pregnancy and has not at any time after being completely expelled from its mother breathed or shown any sign of life (Fraser and Cooper, 2003).
Intrapartum stillbirth: The delivery of any foetus after 28 weeks of gestation, or with a birth weight more than 1000 g, who had detectable foetal heart sounds upon admission, but died during the intrapartum period and therefore had an Apgar score of 0 at 1 and 5 min, without signs of maceration (Kedar & Mats, 2016).
1.9 Operational definitions
Intrapartum stillbirth: Implies that death occurred less than 12 hours before delivery after 28 weeks of gestation,