Risk Factors of Stillbirth among Mothers delivered in Public Hospitals of Central Zone

Risk Factors of Stillbirth among Mothers delivered in Public Hospitals of Central Zone, Tigray, EthiopiaHagos Tasew*1, Micheal Zemicheal2, Girmay Teklay1, Teklewoini Mariye1, Ebud Ayele1
HT: [email protected]: [email protected]
GT: g[email protected]: [email protected]: [email protected]
1 School of Nursing, College of Health Science and Comprehensive Specialized Hospital, Aksum University, Tigray, Ethiopia.
2 School of Medicine, College of Health Science and Comprehensive Specialized Hospital, Aksum University, Tigray, Ethiopia.

*Corresponding author: Hagos TasewEmail: [email protected].

Abstract
Background: Stillbirth (fetal death) as death before the complete expulsion or extraction from its mother. It is worldwide problem; however, in developing countries, the burden is severed and high. Risk factors for stillbirth weren’t studied in Ethiopia yet. This paper fills this research gap and provides as baseline data for developing countries.

Objective: The aim of the study was to identify risk factors of stillbirth among mothers delivered in public hospitals of Central Zone Tigray, Ethiopia in 2018.
Results: A total of 63 cases and 252 controls were included in this study. According to multivariable logistic regression analysis showed that maternal hypertension AOR=12.83; 95% CI (3.38, 48.83), low birth weight AOR=5.6; 95% CI (2.393, 13.38), preterm AOR=2.6;95%CI (1.119,6.158), alcohol intake AOR=7.56; 95% CI (1.679, 34.04), polyhydramnios AOR=13.43; 95% CI (3.63, 49.67) and meconium stained amniotic fluid AOR=7.88; 95% CI (1.73, 8.18) were independent risk factors of stillbirth.

Conclusions: Maternal hypertension, alcohol intake, low birth weight, preterm delivery, polyhydramnios and meconium-stained amniotic fluid were risk factors for stillbirth. Most of these variables are preventable by the holistic care of pregnancy, labor and delivery and post-natal care.
Keywords: Stillbirth, Risk Factors, Neonates, Central Zone, Tigray, Ethiopia
IntroductionStillbirth is a medical term which defines a fetus born dead. World health organization defines stillbirth (fetal death) as death before the complete expulsion or extraction from its mother of a product of conception, after 20 weeks pregnancy in developed countries and after 28 weeks of pregnancy in developing countries, which is indicated by the fact that after such separation, the fetus does not show any evidence of life ADDIN EN.CITE ;EndNote;;Cite;;Author;WHO;/Author;;Year;2004;/Year;;RecNum;23;/RecNum;;DisplayText;(1, 2);/DisplayText;;record;;rec-number;23;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;23;/key;;/foreign-keys;;ref-type name=”Report”;27;/ref-type;;contributors;;authors;;author;WHO;/author;;/authors;;secondary-authors;;author;10th revision;/author;;/secondary-authors;;tertiary-authors;;author;World Health Organization;/author;;/tertiary-authors;;/contributors;;titles;;title; International Statistical Classification of Diseases and Related Health Problems;/title;;/titles;;edition;2nd ;/edition;;dates;;year;2004;/year;;/dates;;pub-location; Geneva, Switzerland;/pub-location;;urls;;/urls;;/record;;/Cite;;Cite;;Author;MacDorman MF;/Author;;Year;2009;/Year;;RecNum;24;/RecNum;;record;;rec-number;24;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;24;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;MacDorman MF, Kirmeyer S;/author;;/authors;;/contributors;;titles;;title;The Challenge of Fetal Mortality;/title;;secondary-title;National Center for Health Statistics ;/secondary-title;;/titles;;pages;NCHS Data Brief No 16;/pages;;dates;;year;2009;/year;;/dates;;urls;;/urls;;/record;;/Cite;;/EndNote;(1, 2). WHO estimates that globally 3.3 million stillbirths occur each year, accounting for over half of all perinatal deaths ADDIN EN.CITE ;EndNote;;Cite;;Author;Organization;/Author;;Year;2006;/Year;;RecNum;27;/RecNum;;DisplayText;(3, 4);/DisplayText;;record;;rec-number;27;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;27;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;World Health Organization;/author;;/authors;;/contributors;;titles;;title;Neonatal and perinatal mortality. Country, regional and global estimates. Geneva, Switzerland;/title;;secondary-title; World Health Organization;/secondary-title;;/titles;;dates;;year;2006;/year;;/dates;;urls;;/urls;;/record;;/Cite;;Cite;;Author;Stanton C;/Author;;Year;2006;/Year;;RecNum;28;/RecNum;;record;;rec-number;28;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;28;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Stanton C, Lawn JE, Rahman H, et al.;/author;;/authors;;/contributors;;titles;;title; Stillbirth rates: Delivering estimates in 190 countries;/title;;secondary-title;Lancet ;/secondary-title;;/titles;;pages;1487–1494;/pages;;volume;367;/volume;;dates;;year;2006;/year;;/dates;;urls;;/urls;;/record;;/Cite;;/EndNote;(3, 4). The majority of these deaths take place in developing countries. While countries in South-East Asia report the highest overall numbers of stillbirths, countries in Africa have the highest incidence rates per 1000 live births. The poorest countries have the highest incidences with two regions, sub-Saharan Africa and South Asia, together accounting for nearly 70% of worldwide stillbirths ADDIN EN.CITE ;EndNote;;Cite;;Author;Organization;/Author;;Year;2006;/Year;;RecNum;27;/RecNum;;DisplayText;(3);/DisplayText;;record;;rec-number;27;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;27;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;World Health Organization;/author;;/authors;;/contributors;;titles;;title;Neonatal and perinatal mortality. Country, regional and global estimates. Geneva, Switzerland;/title;;secondary-title; World Health Organization;/secondary-title;;/titles;;dates;;year;2006;/year;;/dates;;urls;;/urls;;/record;;/Cite;;/EndNote;(3). In high-income countries, stillbirth rates are as low as 6 per 1000 live births, whereas in limited resources countries they can be as high as 26 per 1000 live births ADDIN EN.CITE ;EndNote;;Cite;;Author;Say L;/Author;;Year;2006;/Year;;RecNum;26;/RecNum;;DisplayText;(5);/DisplayText;;record;;rec-number;26;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;26;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Say L, Donner A, Gu¨lmezoglu AM, et al. ;/author;;/authors;;/contributors;;titles;;title;The prevalence of stillbirths: A systematic review;/title;;secondary-title;. Reprod Health ;/secondary-title;;/titles;;volume;3;/volume;;number;1;/number;;dates;;year;2006;/year;;/dates;;urls;;/urls;;/record;;/Cite;;/EndNote;(5).

The high rates of stillbirth result from poor maternal health and inadequate antenatal and post-partum care. Limited health services undeniably constitute the major factor in perinatal mortality, but there is growing concern that high stillbirth rates in many regions are also being driven by less apparent, potentially preventable factors ADDIN EN.CITE ;EndNote;;Cite;;Author;Jonathan M Spectora;/Author;;Year;2013;/Year;;RecNum;29;/RecNum;;DisplayText;(6);/DisplayText;;record;;rec-number;29;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;29;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;;style face=”normal” font=”default” size=”100%”; Jonathan M Spector;/style;;style face=”superscript” font=”default” size=”100%”;a;/style;;style face=”normal” font=”default” size=”100%”;, Subhansh Daga;/style;;style face=”superscript” font=”default” size=”100%”;b;/style;;/author;;/authors;;/contributors;;titles;;title;preventing those so-called stillbirths;/title;;secondary-title;World Health Organization;/secondary-title;;/titles;;dates;;year;2013;/year;;/dates;;urls;;/urls;;/record;;/Cite;;/EndNote;(6). Thus, stillbirth is a public health as well as a development problem on the continent, as in other low-income regions. Yet the grief endured by parents who have had a stillbirth in these settings remains untold. Stillbirth in low-income countries leaves the parents with many challenges, such as ill health, grief, sadness, and coping with community perceptions ADDIN EN.CITE ;EndNote;;Cite;;Author;Stanton C;/Author;;Year;2006;/Year;;RecNum;28;/RecNum;;DisplayText;(4, 7);/DisplayText;;record;;rec-number;28;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;28;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Stanton C, Lawn JE, Rahman H, et al.;/author;;/authors;;/contributors;;titles;;title; Stillbirth rates: Delivering estimates in 190 countries;/title;;secondary-title;Lancet ;/secondary-title;;/titles;;pages;1487–1494;/pages;;volume;367;/volume;;dates;;year;2006;/year;;/dates;;urls;;/urls;;/record;;/Cite;;Cite;;Author;Kiguli;/Author;;Year;2016;/Year;;RecNum;25;/RecNum;;record;;rec-number;25;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;25;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Kiguli, Juliet;/author;;author;Munabi, Ian G.;/author;;author;Ssegujja, Eric;/author;;author;Nabaliisa, Joyce;/author;;author;Kabonesa, Consolata;/author;;author;Kiguli, Sarah;/author;;author;Josaphat, Byamugisha;/author;;/authors;;/contributors;;titles;;title;Stillbirths in sub-Saharan Africa: unspoken grief;/title;;secondary-title;The Lancet;/secondary-title;;/titles;;periodical;;full-title;The Lancet;/full-title;;/periodical;;pages;e16-e18;/pages;;volume;387;/volume;;number;10018;/number;;dates;;year;2016;/year;;/dates;;publisher;Elsevier;/publisher;;isbn;0140-6736;/isbn;;urls;;related-urls;;url;http://dx.doi.org/10.1016/S0140-6736(15)01171-X;/url;;/related-urls;;/urls;;electronic-resource-num;10.1016/S0140-6736(15)01171-X;/electronic-resource-num;;access-date;2018/06/19;/access-date;;/record;;/Cite;;/EndNote;(4, 7).
Largely devastating is the occurrence of a term stillbirth, a proportion of which has no clinical elucidation or certain cause in spite of a complete evaluation. The potential risk factors for stillbirths, including maternal factors consisting of demographic, environmental, nutritional, and lifestyle factors, maternal infections and non-communicable diseases, and fetal factors, which are considered modifiable risk factors ADDIN EN.CITE ;EndNote;;Cite;;Author;Lawn;/Author;;Year;2016;/Year;;RecNum;30;/RecNum;;DisplayText;(8);/DisplayText;;record;;rec-number;30;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;30;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Lawn, Joy E;/author;;author;Blencowe, Hannah;/author;;author;Waiswa, Peter;/author;;author;Amouzou, Agbessi;/author;;author;Mathers, Colin;/author;;author;Hogan, Dan;/author;;author;Flenady, Vicki;/author;;author;Frøen, J Frederik;/author;;author;Qureshi, Zeshan U;/author;;author;Calderwood, Claire;/author;;/authors;;/contributors;;titles;;title;Stillbirths: rates, risk factors, and acceleration towards 2030;/title;;secondary-title;The Lancet;/secondary-title;;/titles;;periodical;;full-title;The Lancet;/full-title;;/periodical;;pages;587-603;/pages;;volume;387;/volume;;number;10018;/number;;dates;;year;2016;/year;;/dates;;isbn;0140-6736;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(8). The fact that most of the stillbirths were fresh suggests that higher quality intrapartum care could reduce stillbirth rates ADDIN EN.CITE ;EndNote;;Cite;;Author;Yatich;/Author;;Year;2010;/Year;;RecNum;18;/RecNum;;DisplayText;(9);/DisplayText;;record;;rec-number;18;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;18;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Yatich, Nelly J;/author;;author;Funkhouser, Ellen;/author;;author;Ehiri, John E;/author;;author;Agbenyega, Tsiri;/author;;author;Stiles, Jonathan K;/author;;author;Rayner, Julian C;/author;;author;Turpin, Archer;/author;;author;Ellis, William O;/author;;author;Jiang, Yi;/author;;author;Williams, Jonathan H;/author;;/authors;;/contributors;;titles;;title;Malaria, intestinal helminths and other risk factors for stillbirth in Ghana;/title;;secondary-title;Infectious diseases in obstetrics and gynecology;/secondary-title;;/titles;;volume;2010;/volume;;dates;;year;2010;/year;;/dates;;isbn;1064-7449;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(9).

There are few literatures on stillbirths in developed countries, but there is too few number of articles devoted to stillbirths in developing countries. It is important to conduct further studies to investigate risk factors of stillbirth to determine which stillbirths are preventable so that targeted interventions can be developed and tailored for limited resource settings ADDIN EN.CITE ;EndNote;;Cite;;Author;Yatich;/Author;;Year;2010;/Year;;RecNum;18;/RecNum;;DisplayText;(9);/DisplayText;;record;;rec-number;18;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;18;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Yatich, Nelly J;/author;;author;Funkhouser, Ellen;/author;;author;Ehiri, John E;/author;;author;Agbenyega, Tsiri;/author;;author;Stiles, Jonathan K;/author;;author;Rayner, Julian C;/author;;author;Turpin, Archer;/author;;author;Ellis, William O;/author;;author;Jiang, Yi;/author;;author;Williams, Jonathan H;/author;;/authors;;/contributors;;titles;;title;Malaria, intestinal helminths and other risk factors for stillbirth in Ghana;/title;;secondary-title;Infectious diseases in obstetrics and gynecology;/secondary-title;;/titles;;volume;2010;/volume;;dates;;year;2010;/year;;/dates;;isbn;1064-7449;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(9). Consequently, this article was tried to investigate risk factors of stillbirth and strategies that might reduce their number. It helps also as a baseline data for the country as well as for the continent.
Methods and materials
Study Area and Period
The study was carried out in public Hospitals of Central Zone. Data collection for this study was undertaken from January up to April 2018.
Study DesignA facility based unmatched case-control study design was employed.

Source PopulationThe source population was all mothers came for delivery in public hospitals.

Study PopulationFor cases: Mothers with their newborns who diagnosis as stillbirth.
For controls: Mothers with their newborns with live birth.

Sample Size CalculationSample size of the study was calculated using EPI Info software version 7.1.1 with the following parameters for unmatched case control study: Confidence level = 95%; Power = 80%; Odds ratio = 2.33; Case to control ratio = 1: 4; Proportion of controls with exposure 29.4 % ADDIN EN.CITE ;EndNote;;Cite;;Author;Group;/Author;;Year;2011;/Year;;RecNum;11;/RecNum;;DisplayText;(10);/DisplayText;;record;;rec-number;11;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;11;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Stillbirth Collaborative Research Network Writing Group;/author;;/authors;;/contributors;;titles;;title;Association between stillbirth and risk factors known at pregnancy confirmation;/title;;secondary-title;JAMA: the journal of the American Medical Association;/secondary-title;;/titles;;volume;306;/volume;;number;22;/number;;dates;;year;2011;/year;;/dates;;urls;;/urls;;/record;;/Cite;;/EndNote;(10); Proportion of cases with exposure = 49.2 % ADDIN EN.CITE ;EndNote;;Cite;;Author;Group;/Author;;Year;2011;/Year;;RecNum;11;/RecNum;;DisplayText;(10);/DisplayText;;record;;rec-number;11;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;11;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Stillbirth Collaborative Research Network Writing Group;/author;;/authors;;/contributors;;titles;;title;Association between stillbirth and risk factors known at pregnancy confirmation;/title;;secondary-title;JAMA: the journal of the American Medical Association;/secondary-title;;/titles;;volume;306;/volume;;number;22;/number;;dates;;year;2011;/year;;/dates;;urls;;/urls;;/record;;/Cite;;/EndNote;(10) the total sample size for cases=63; sample size for controls =252 the overall sample size was = 315.
Sampling Technique
Systematic random sampling technique was used to select the study subjects from four public hospitals with every two study subjects for both cases and controls.

Study Variables
Dependent variable:
Stillbirth
Independent variables:
Antepartum factors
Intrapartum factors Fetal factorsOperational Definitions
The cases of the study were determined with clinical features. Assess, look of breathing on following signs
Is baby not breathing? Or if the baby has not any sign of life, patients were diagnosed as stillbirth or case of the study.

Data Collection Tool and ProcedureThe questionnaire was initially prepared in English and then translated into Tigrigna. Data was collected using interviewer-administered structured questionnaire adapted, observational and chart analysis. The questioner reliability was checked using Cronbach’s alpha. Data Quality ControlQuality of the data was assured with properly designed data collection instruments. The enumerators and the supervisor were given training for three days on procedures, techniques, and ways of collecting the data. Five percent pretest was done at Shul hospital to check consistency the questioner. The collected data was reviewed and checked for completeness by the principal investigator and co-investigators weekly.

Plan for Data Processing and AnalysisData were entered and cleaned using Epi info version 7.1.1. Data were analyzed using SPSS version 22.0 statistical software and variables which were show statistical significance during bivariate analysis at p-value ? 0.25 were entered into multivariable logistic regression. Data was finally presented and interpreted at P-value < 0.05 were considered as statistically significant.

Results
5.1 Socio-demographic characteristics of study participantsIn this study, a total of 63 participants who had stillbirths (cases) with their index mothers and 252 participants who had live births (controls) with their index mothers were included making a response rate of 100%. Thirty-eight (60.3 %) of cases and 97 (38.5%) controls were living in rural areas. Regarding marital status, 51 (81.0 %) cases and 236 (93.7%) of controls were married. Thirty-nine (61.9 %) of cases and 118 (46.8 %) of controls were housewives and 20 (31.7 %) cases and 38 (15.1 %) of controls were not able to read and write (Table1).

Table SEQ Table * ARABIC 1: Distribution of socio-demographic characteristics of cases and controls attending public hospitals of Central zone, Tigray Region, Ethiopia.

Variables Category Cases
n=63(%) Controls
n=252(%) Total
n=315(%)
Religion Orthodox
Muslim and others 54(85.7)
9(14.3) 220(87.3)
32 (12.7) 274(87.0)
41(13.0)
Residence Urban
Rural 25(39.7)
38(60.3) 155(61.5)
97(38.5) 180(57.1)
135(42.9)
Educational status Unable to write and read
Primary school
Secondary school
Diploma and above 20(31.7)
20(22.7)
24(27.3)
14(15.9) 28(15.9)
48(27.3)
67(38.1)
33(18.8) 58(22.0)
68(25.8)
91(34.5)
47(17.8)
Marital status Married
Single
Divorced 75(85.2)
11(12.5)
2(2.3) 166(94.3)
8(4.5)
2(1.1) 241(91.3)
19(7.2)
4(1.5)
Occupational status Housewife
Civil servant
Private worker
Farmer
Student 47(53.4)
8(9.1)
15(17.0)
9(10.2)
9(10.2) 89(50.6)
30(17.0)
29(16.5)
18(10.2)
10(5.7) 136(51.5)
38(14.4)
44(16.7)
27(10.2)
19(7.2)
5.2 Antepartum factors of study participants
Fifty-three (84.1%) cases and 227 (90.1%) controls had antenatal care follow up and 6 (9.5%) cases and 5(2.0%) controls were had preeclampsia. Fourteen (22.2%) cases and 6(2.4%) controls were with the complication of polyhydramnios and 8(12.7%) cases and 9(3.6%) controls were had oligohydramnios as a complication. Twelve (19.0 %) cases and 9(3.6 %) controls were anemic patients and 14(22.2 %) cases and 14 (5.6 %) controls were had maternal infection. Six (1.9%) cases had experience of having a history of smoking, 13 (20.6 %) cases and 44(17.5 %) controls had history abortion. Twenty-two (34.9 %) cases and 101 (40.1 %) controls were primiparous parity.
Table 2: Distribution of antepartum factors of cases and controls attending public hospitals of Central zone, Tigray Region, North Ethiopia 2018.

Variables Category Cases
n=63(%) Controls
n=252(%) Total
ANC visit Yes
No 33(84.1)
10(15.9) 227(90.1)
25(9.9) 280(88.9)
35(11.1)
Preeclampsia Yes
No 6(9.5)
57(90.5) 5(2.0)
247(98.0) 11(3.5)
304(96.5)
Maternal DM Yes
No 8(12.7)
55(87.3) 8(3.2)
244(96.8) 16(5.1)
299(94.9)
Previous RH+ Sensitization Yes
No 8(9.1)
55(90.9) 6(1.9)
246(78.1) 14(4.4)
301(95.5)
Antepartum hemorrhage Yes
No 12(19.0)
51(81.0) 8(3.2)
244(96.8) 20(6.3)
295(93.7)
Polyhydramnios Yes
No 14(22.2)
49(77.8) 6(2.4)
246(97.6) 20(6.3)
295(93.7)
Oligohydramnios Yes
No 8(12.7)
55(87.3) 9(3.6)
243(96.4) 17(5.4)
298(94.8)
Maternal infection Yes
No 14(22.2)
49(77.8) 14(5.6)
238(94.4) 28(8.9)
287(91.1)
Anemia Yes
No 12(19.0)
49(77.8) 6(2.4)
246(97.6) 20(6.3)
295(93.7)
History of abortion Yes
No 13(20.6)
50(79.4) 44(17.5)
208(82.5) 57(18.1)
258(81.9)
Alcohol Yes
No 8(12.7)
55(87.3) 5(2.0)
247(98.0) 13(4.1)
302(95.9)
Type of pregnancy Single
Twin and above 57(90.5)
6(9.5) 239(94.8)
13(5.2) 296(94.0)
19(6.0)
Maternal hypertension Yes
No 14(22.2)
49(77.8) 6(2.4)
246(97.6) 20(6.3)
295(93.7)
Medical problem Yes
No 12(19.0)
51(81.0) 26(10.3)
226(89.7) 38(12.1)
277(87.9)
Parity PrimiparousMultiparous 22(34.9)
41(65.1) 101(40.1)
151(59.9) 123(39.0)
192(61.0)
BMI Underweight
Normal weight
Overweight 11(17.5)
39(61.9)
13(20.6) 11(4.4)
220(87.3)
21(8.3) 22(7.0)
259(82.2)
34(10.8)
5.3 Distributions of intrapartum and fetal factors among participants
Fifteen (23.8%) cases and 53(21.0%) controls were had experience of prolonged labor and 2 (3.2%) cases and 14 (5.6 %) controls were had a prolapsed cord as a complication of labor. Fifty-three (84.1%) cases and 185(73.4%) controls were delivered spontaneously and 34 (54.0%) cases and 224(88.9%) controls were had vertex presentation. Fifteen (23.8%) cases and 23(9.1%) controls were had meconium stained on pelvic examination. Thirty-six (57.1%) cases and 43 (17.1%) controls were low birth weight and 40(63.5%) cases and 68(27.0%) and controls were preterm (Table 3).
Table 3: Distribution of intrapartum and fetal factors of cases and controls attending public hospitals of Central zone, Tigray Region, Ethiopia 2018.

Variables Category Cases
n=63(%) Controls
n=252(%) Total
Prolonged labor Yes
No 15(23.8)
48(76.2) 53(21.0)
199(79.0) 68(21.6)
247(78.4)
Prolapsed cord Yes
No 2(3.2)
61(96.8) 14(5.6)
238(94.4) 16(5.1)
299(94.9)
Mode of delivery Spontaneous
Instrumental
Cesarean section 53(84.1)
5(7.9)
5(7.9) 185(73.4)
21(8.3)
46(18.3) 238(75.6)
26(8.3)
51(16.2)
Presentation Vertex
Breech and others 34(54.0)
29(46.0) 224(88.9)
28(11.1) 258(81.9)
57(18.1)
Muonium stained Yes
No 15(23.8)
48(76.2) 23(9.1)
229(90.9) 38(12.1)
277(87.9)
CPD Yes
No 2(3.2)
61(96.6) 10(4.0)
242(96.0) 12(3.8)
303(96.2)
PROM Yes
No 14(22.2)
49(77.4) 52(20.6)
200(79.8) 66(21.0)
249(79.0)
Placental abruption Yes
No 13(20.6)
50(79.4) 8(3.2)
244(96.8) 21(6.7)
294(93.3)
Weight of newborn <2.5kg
?2.5kg 36(57.1)
27(42.5) 43(17.1)
209(82.9) 79(25.1)
236(74.9)
GA <37weeks
?37weeks 40(63.5)
23(36.5) 68(27.0)
184(73.0) 108(34.8)
207(65.7)
5.4 Risk factors for stillbirth
In bivariate analysis, 17 variables did show a significant association with a stillbirth at 25 % level of significance. Multivariable logistic regression was done by taking 17 variables into account simultaneously. The backward elimination method of regression was used to assess the confounding.
Maternal hypertension was showed a significant association with stillbirth. The odds of maternal hypertension were 12.83 times higher compared to those who were that AOR=12.83; 95% CI (3.38, 48.83).
Polyhydramnios was significantly associated with stillbirth. Those who were had polyhydramnios 13.43 times higher risk than those who have not had it, to develop stillbirth AOR=13.43; 95% CI (3.63, 49.67).
Alcohol drinking was significantly associated with stillbirth. Mothers who drank alcohol were 7.56 times higher risk than those who were not drunk that to the outcome of stillbirth AOR=7.56; 95% CI (1.679, 34.04).
Status of meconium-stained had a significant association with the outcome variable of stillbirth. Those who had meconium stained were 3.1 times higher risk than were not had meconium stained to stillbirth AOR=7.88; 95% CI (1.73, 8.18).
Preterm babies were 2.6 times higher risk than term developing stillbirth AOR=2.6;95%CI (1.119,6.158). Similarly, the weight of the neonate had also a significant association with stillbirth. Low birth weight neonates were 5.6 times higher at risk than normal weight as a determinant of stillbirth AOR=5.6; 95% CI (2.393, 13.38) (Table 4).

Table 4: Bivariate and multivariable logistic regression among factors of cases and controls attending public hospitals of Central zone, Tigray Region, North Ethiopia 2018.

Variables Category Cases
n=63(%) Controls
n=252(%) COR 95%CI) AOR 95%CL)
Residence Urban
Rural 25(39.7)
38(60.3) 155(61.5)
97(38.5) 1
2.429 (1.381,4.273) 1
1.209(0.558,2.024)
Educational status Unable to write and
Primary school
Secondary school
Diploma and above 20(31.7)
17(27.0)
18(28.6)
8(12.7) 38(15.1)
66(26.2)
99(39.3)
49(19.4) 3.224(1.281, 8.113)
1.575(0.630, 3.951)
0.982(0.435,2.217)
1 2.256(0.661,7.701)
1.707(0.553,5.269)
0.800(0.255,2.514)
1
ANC visit Yes
No 33(84.1)
10(15.9) 227(90.1)
25(9.9) 1.713(0.776,3.782)
1 1.893(0.604,5.026)
1
Maternal DM Yes
No 8(12.7)
55(87.3) 8(3.2)
244(96.8) 4.436(1.598,12.336)
1 0.910(0.143,5.790)
1
Maternal hypertension Yes
No 14(22.2)
49(77.8) 6(2.4)
246(97.6) 11.71(4.291,31.98)
1 12.83(3.375,48.832) *
1
Maternal infection Yes
No 14(22.2)
49(77.8) 14(5.6)
238(94.4) 4.85(2.178,10.532)
1 2.074(0.692,6.223)
1
Antepartum hemorrhage Yes
No 12(19.0)
51(81.0) 8(3.2)
244(96.8) 7.17(2.792,18.446)
1 2.218(0.673,7.311)
1
Preeclampsia Yes
No 6(9.5)
57(90.5) 5(2.0)
247(98.0) 5.2(1.533,17.636)
1 0.910(0.143,5.790)
1
Polyhydramnios Yes
No 12(19.6)
51(81.0) 4(1.6)
248(98.4) 11.71(4291,31.980)
1 13.43(3.634,49.669)*
1
Alcohol Yes
No 8(12.7)
55(87.3) 5(2.0)
247(98.0) 7.185(2.264,22.805)
1 7.561(1.679,34.044)*
1
Oligohydramnios Yes
No 8(12.7)
55(87.3) 9(3.6)
243(96.4) 3.927(1.480.10,636)
1 0.777(0.178,3.399)
1
Weight of newborn <2.5kg
?2.5kg 36(57.1)
27(42.5) 43(17.1)
209(82.9) 6.481(3.566,11.776)
1 5.658(2.393,13.376) *
1
GA <37weeks
?37weeks 40(63.5)
23(36.5) 68(27.0)
184(73.0) 4.706(2.626,8.434)
1 2.625(1.119,6.158) *
1
Muonium stained Yes
No 15(23.8)
48(76.2) 23(9.1)
229(90.9) 3.111(1.513,6.399)
1 3.15(1.73,8.179) *
1
BMI Underweight
Normal weight
Overweight 11(17.5)
39(61.9)
13(20.6) 11(4.4)
220(87.3)
21(8.3) 0.177(0.072,0.437)
0.619(0.209,1.832)
1 1.185(0252,5.603)
0.461(0.144,1.478)
1
Medical problem Yes
No 12(19.0)
51(81.0) 26(10.3)
226(89.7) 2.045(0.968,4.323)
1 3.24(0.789,5.654)
1
Placental abruption Yes
No 13(20.6)
50(79.4) 8(3.2)
244(96.8) 7.936(3.123,20.135)
1 1.63(0.387,564)
1
Discussion
This study was aimed to assess risk factors of stillbirth in order to tackle the burden of the outcome. It has attempted to look the determinants of stillbirth by incorporating as many risk factors as possible.
This study, those with maternal hypertension were significantly at risk of stillbirth. Those who had maternal hypertension were 12.83 times higher at risk than those who were free of hypertension during pregnancy. This result is consistent with previous reports PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5GbGVuYWR5PC9BdXRob3I+PFllYXI+MjAxMTwvWWVhcj48
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ADDIN EN.CITE.DATA (11-13). This may be due to maternal hypertension may be the result of abruptio placentae, uteroplacental insufficiency, placental infarction, or fetal-maternal hemorrhage. Due to, those reasons maternal hypertension may decrease fetal growth. Fetal-maternal hemorrhage causes elevated maternal serum ?-fetoprotein found to be a marker of stillbirth.

Birth weight showed a significant association with stillbirth. Low birth weight was 5.65 times more likely to be stillbirth than normal weight (? 2500g). This finding is similar with studies conducted in a different setting ADDIN EN.CITE <EndNote><Cite><Author>Lawn</Author><Year>2016</Year><RecNum>30</RecNum><DisplayText>(8, 14)</DisplayText><record><rec-number>30</rec-number><foreign-keys><key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”>30</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Lawn, Joy E</author><author>Blencowe, Hannah</author><author>Waiswa, Peter</author><author>Amouzou, Agbessi</author><author>Mathers, Colin</author><author>Hogan, Dan</author><author>Flenady, Vicki</author><author>Frøen, J Frederik</author><author>Qureshi, Zeshan U</author><author>Calderwood, Claire</author></authors></contributors><titles><title>Stillbirths: rates, risk factors, and acceleration towards 2030</title><secondary-title>The Lancet</secondary-title></titles><periodical><full-title>The Lancet</full-title></periodical><pages>587-603</pages><volume>387</volume><number>10018</number><dates><year>2016</year></dates><isbn>0140-6736</isbn><urls></urls></record></Cite><Cite><Author>Feresu</Author><Year>2004</Year><RecNum>8</RecNum><record><rec-number>8</rec-number><foreign-keys><key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”>8</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Feresu, Shingairai A</author><author>Harlow, Siobán D</author><author>Welch, Kathy</author><author>Gillespie, Brenda W</author></authors></contributors><titles><title>Incidence of and socio?demographic risk factors for stillbirth, preterm birth and low birthweight among Zimbabwean women</title><secondary-title>Paediatric and perinatal epidemiology</secondary-title></titles><periodical><full-title>Paediatric and perinatal epidemiology</full-title></periodical><pages>154-163</pages><volume>18</volume><number>2</number><dates><year>2004</year></dates><isbn>1365-3016</isbn><urls></urls></record></Cite></EndNote>(8, 14) presented that low birth weight was a risk factor for stillbirth. This may be due to the fact that low birth weight was developed due to a maternal complication like hypertension, diabetes mellitus that present pre-conception or antepartum.
Preterm babies were 2.6 times more likely at risk of stillbirth than term babies. This study is in line with previous studies ADDIN EN.CITE <EndNote><Cite><Author>Feresu</Author><Year>2004</Year><RecNum>8</RecNum><DisplayText>(14, 15)</DisplayText><record><rec-number>8</rec-number><foreign-keys><key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”>8</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Feresu, Shingairai A</author><author>Harlow, Siobán D</author><author>Welch, Kathy</author><author>Gillespie, Brenda W</author></authors></contributors><titles><title>Incidence of and socio?demographic risk factors for stillbirth, preterm birth and low birthweight among Zimbabwean women</title><secondary-title>Paediatric and perinatal epidemiology</secondary-title></titles><periodical><full-title>Paediatric and perinatal epidemiology</full-title></periodical><pages>154-163</pages><volume>18</volume><number>2</number><dates><year>2004</year></dates><isbn>1365-3016</isbn><urls></urls></record></Cite><Cite><Author>McCOWAN</Author><Year>2007</Year><RecNum>15</RecNum><record><rec-number>15</rec-number><foreign-keys><key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”>15</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>McCOWAN, Lesley ME</author><author>GEORGE?HADDAD, Maha</author><author>Stacey, Tomasina</author><author>Thompson, John</author></authors></contributors><titles><title>Fetal growth restriction and other risk factors for stillbirth in a New Zealand setting</title><secondary-title>Australian and New Zealand Journal of Obstetrics and Gynaecology</secondary-title></titles><pages>450-456</pages><volume>47</volume><number>6</number><dates><year>2007</year></dates><isbn>1479-828X</isbn><urls></urls></record></Cite></EndNote>(14, 15) discovered that preterm babies had culprits on a stillbirth. This may be due to premature infants are more susceptible to ischemia due to incomplete blood-brain barrier formation. Moreover, it may be due to the fact that preterm babies face multiple morbidities including organ system, immaturity especially lung immaturities causing respiratory failure.

Meconium stained mothers had a significant association with a stillbirth. Those who had meconium stained were 13 times higher risk than were not had meconium stained to stillbirth. This study is in line with other previous studies ADDIN EN.CITE <EndNote><Cite><Author>Geenes</Author><Year>2014</Year><RecNum>31</RecNum><DisplayText>(16, 17)</DisplayText><record><rec-number>31</rec-number><foreign-keys><key app=”EN” db-id=”22dvetprqddwave0w5g5rfwu95fds9z9fsf5″>31</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Geenes, Victoria</author><author>Chappell, Lucy C</author><author>Seed, Paul T</author><author>Steer, Philip J</author><author>Knight, Marian</author><author>Williamson, Catherine</author></authors></contributors><titles><title>Association of severe intrahepatic cholestasis of pregnancy with adverse pregnancy outcomes: A prospective population?based case?control study</title><secondary-title>Hepatology</secondary-title></titles><periodical><full-title>Hepatology</full-title></periodical><pages>1482-1491</pages><volume>59</volume><number>4</number><dates><year>2014</year></dates><isbn>1527-3350</isbn><urls></urls></record></Cite><Cite><Author>Rathorea</Author><Year>2002</Year><RecNum>32</RecNum><record><rec-number>32</rec-number><foreign-keys><key app=”EN” db-id=”22dvetprqddwave0w5g5rfwu95fds9z9fsf5″>32</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Rathorea, Asmita Muthal</author><author>Singh, Ruchira</author><author>Ramji, S</author><author>Tripathi, Reva</author></authors></contributors><titles><title>Randomised trial of amnioinfusion during labour with meconium stained amniotic fluid</title><secondary-title>BJOG: an international journal of obstetrics &amp; gynaecology</secondary-title></titles><periodical><full-title>BJOG: An International Journal of Obstetrics &amp; Gynaecology</full-title></periodical><pages>17-20</pages><volume>109</volume><number>1</number><dates><year>2002</year></dates><isbn>1471-0528</isbn><urls></urls></record></Cite></EndNote>(16, 17). In healthy, well-oxygenated fetuses, this diluted meconium is readily cleared from the lungs by the normal physiological mechanism. However, in a few cases, meconium aspiration syndrome occurs then after babies with that complication will bear still.

Alcohol drinking had a significant association with stillbirth. The odds those who were drunk of alcohol 7.6 times higher risk than those who weren’t drunk alcohol for the effect stillbirth. This study is consistent with other studies ADDIN EN.CITE ;EndNote;;Cite;;Author;Henderson;/Author;;Year;2007;/Year;;RecNum;33;/RecNum;;DisplayText;(18, 19);/DisplayText;;record;;rec-number;33;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;33;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Henderson, Jane;/author;;author;Gray, Ron;/author;;author;Brocklehurst, Peter;/author;;/authors;;/contributors;;titles;;title;Systematic review of effects of low–moderate prenatal alcohol exposure on pregnancy outcome;/title;;secondary-title;BJOG: An International Journal of Obstetrics ;amp; Gynaecology;/secondary-title;;/titles;;periodical;;full-title;BJOG: An International Journal of Obstetrics ;amp; Gynaecology;/full-title;;/periodical;;pages;243-252;/pages;;volume;114;/volume;;number;3;/number;;dates;;year;2007;/year;;/dates;;isbn;1471-0528;/isbn;;urls;;/urls;;/record;;/Cite;;Cite;;Author;Kesmodel;/Author;;Year;2002;/Year;;RecNum;31;/RecNum;;record;;rec-number;31;/rec-number;;foreign-keys;;key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”;31;/key;;/foreign-keys;;ref-type name=”Journal Article”;17;/ref-type;;contributors;;authors;;author;Kesmodel, Ulrik;/author;;author;Wisborg, Kirsten;/author;;author;Olsen, Sjúrður Fróði;/author;;author;Henriksen, Tine Brink;/author;;author;Secher, Niels Jørgen;/author;;/authors;;/contributors;;titles;;title;Moderate alcohol intake during pregnancy and the risk of stillbirth and death in the first year of life;/title;;secondary-title;American journal of epidemiology;/secondary-title;;/titles;;periodical;;full-title;American journal of epidemiology;/full-title;;/periodical;;pages;305-312;/pages;;volume;155;/volume;;number;4;/number;;dates;;year;2002;/year;;/dates;;isbn;1476-6256;/isbn;;urls;;/urls;;/record;;/Cite;;/EndNote;(18, 19). This may be due to the fact that mainly because of fetoplacental dysfunction. Another reason could be alcohol can result in low birth weight and preterm; those factors had an effect with a stillbirth.
Polyhydramnios had a significant association with the stillbirth. Mothers who had polyhydramnios had a 12 times higher risk than those who haven’t had polyhydramnios to the outcome of stillbirth. This study is in line with studies reported previously ADDIN EN.CITE <EndNote><Cite><Author>Sharma</Author><Year>2007</Year><RecNum>34</RecNum><DisplayText>(20, 21)</DisplayText><record><rec-number>34</rec-number><foreign-keys><key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”>34</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Sharma, Puza P</author><author>Salihu, Hamisu M</author><author>Kirby, Russel S</author></authors></contributors><titles><title>Stillbirth recurrence in a population of relatively low?risk mothers</title><secondary-title>Paediatric and perinatal epidemiology</secondary-title></titles><periodical><full-title>Paediatric and perinatal epidemiology</full-title></periodical><pages>24-30</pages><volume>21</volume><dates><year>2007</year></dates><isbn>0269-5022</isbn><urls></urls></record></Cite><Cite><Author>Furman</Author><Year>2000</Year><RecNum>35</RecNum><record><rec-number>35</rec-number><foreign-keys><key app=”EN” db-id=”2pfepeptwzpsrae2rf3pvpvqftfe09v59e5s”>35</key></foreign-keys><ref-type name=”Journal Article”>17</ref-type><contributors><authors><author>Furman, Boris</author><author>Erez, Offer</author><author>Senior, Leon</author><author>SHOHAM?VARDI, ILANA</author><author>BAR?DAVID, JURY</author><author>Maymon, Eli</author><author>Mazor, Moshe</author></authors></contributors><titles><title>Hydramnios and small for gestational age: prevalence and clinical significance</title><secondary-title>Acta obstetricia et gynecologica Scandinavica</secondary-title></titles><periodical><full-title>Acta obstetricia et gynecologica Scandinavica</full-title></periodical><pages>31-36</pages><volume>79</volume><number>1</number><dates><year>2000</year></dates><isbn>1600-0412</isbn><urls></urls></record></Cite></EndNote>(20, 21). This could be due to the fact in the polyhydramnios, there is premature labor because of the additional pressure stretching the womb. Additionally, polyhydramnios can lead to the wrong position, the umbilical cord may slip down into the birth canal when the membranes rupture and an increased risk of bleeding after delivery. Consequently, the mother can have a stillbirth.
Conclusion
Stillbirth is one of the worldwide problems of newborns. There are different variables which culprits of stillbirth. In this study, maternal hypertension, alcohol intake, low birth weight, preterm delivery, polyhydramnios and meconium-stained amniotic fluid were risk factors for stillbirth. Most of these variables are preventable by the holistic care of pregnancy, labor and delivery and post-natal care.
Limitation
This study is quantitative, it was better if the qualitative approach was also employed to investigate in detail on extra determinant factors of stillbirth.

Abbreviations
AOR: Adjusted Odd Ratio, COR: Crudes Odd Ratio, SPSS: Statistics Package for Social Science, WHO: World Health Organization, TRHB: Tigray Regional Health Bureau
Declaration
Ethics Approval and Consent to Participate
Ethical clearance was obtained from Aksum University, college of health science, institutional review board (AKU-CHS, IRB) of the research committee. Respondents were informed about the purpose of the study, the information was collected after obtaining written consent from each participant. Written consent was wanted from all the informed respondents before the start of each interview. Respondents were allowed to refuse or discontinue or participation at any time they want. Information was recorded anonymously and confidentiality and beneficence were assured throughout the study.

Availability of Data and Materials
The data sets used and analyzed during the current study available from the corresponding author on reasonable request.

Competing Interests
This manuscript maintains no competing financial interest declaration from any person or organization, or non-financial competing interests such as political, personal, religious, ideological, academic, intellectual, commercial or any other.

Funding:
No funding source was received
Acknowledgments
We would like to thank all study participants and data collectors for their contribution in the success of our work.

Authors’ Contributions:
HT: conceived and designed the study, analyzed the data and wrote the manuscript. MZ, GT, TM and EA involved in data analysis, drafting of the manuscript and advising the whole research paper and also were involved in the interpretation of the data and contributed to manuscript preparation. Similarly, all authors have read and approved the final version of the manuscript.

Consent to Publish: Not applicable
Reference
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