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

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.

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. Funding The Gates Foundation Competing Interest Statement CGW reports other grants from the Bill & Melinda Gates Foundation for work on malnutrition, HIV, and Covid vaccines, other than the submitted work. AW reports being a council member of the national Obstetrician and & Gynaecologists council. KK reports grant from the Bill & Melinda Gates Foundation and support for attending meetings. SEA reports his employment at icddr,b, an organization that receives grants for related projects and funding from WHO & BMGF to support his travels. All other authors declare no competing interests. Funding Statement This project received funding from the Bill & Melinda Gates Foundation (Grant No. OPP1126780). Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Not Applicable The details of the IRB/oversight body that provided approval or exemption for the research described are given below: . Ethics committees in each CHAMPS site and Emory University approved of the study protocols. (https://champshealth.org/resources/protocols/) I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Not Applicable I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Not Applicable I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Not Applicable Data sharing CHAMPS data are available online and requests for further detailed data for research and evaluation purposes can be made at: https://champshealth.org/data/.