Stillbirth rates vary widely between countries. According to Frøen et al., stillbirths are not counted in 90 countries worldwide (10), which make it difficult to estimate the true rates of stillbirths. In the current study, the incidence of stillbirth was found to be 9.9 per 1000 live births. This rate is similar to the rate in Lebanon for the year 2015 (9.9) (11). The rate is higher than the rate of 7.81 per 1000 births that was reported in a multi-ethnic Middle-Eastern based study (4), and that was reported for the year 2015 for some other Arab countries such as Libya (8.8 per 1000 live births), Oman (8.5 per 1000 live births), Qatar (5.8 per 1000 live births), and Kuwait (5.1 per 1000 live births) (11). However, the rate was lower than the rate of 11.6 per 1000 live births that was reported in a previous Jordan study in 2012 (8), and the 2015 rates in other countries such Syria (11.1), Saudia Arabia (13.9), Egypt (12.2), Iraq (15.5), and Jordan (10.5) (11). This decline is promising and might be related to improvements in maternal health care services, yet there remains a room for more improvement. Most of these stillbirths are preventable and more decline in stillbirth rate is possible. In order to achieve lower rates, we need to address possible risk factors and possible contributing conditions of stillbirths.
Our study showed that low birth weight, preterm birth, and multiple gestation are risk factors of stillbirth. These are well known risk factors in the literature and are closely linked to stillbirths (12–15). Low birth weight may result from both fetal growth restriction and preterm birth, which are associated with placental dysfunction and subsequent poor fetal outcomes (2). This increases the risk of both antepartum and intrapartum fetal deaths (2). As stillbirth rates are very sensitive to access to high quality antenatal health care (6), proper assessment and early identification of multiple gestations, gestational age, and birth weight may contribute to the decrease of the incidence of stillbirths.
Although advanced maternal age of > 35 years was reported as a significant factor for increased stillbirth rate (16,17), it was not found to be significant in the current study. The exact mechanism of the increase risk of stillbirth with advanced maternal age is not fully understood (18), which necessitate additional studies to determine the mechanism. However, some research suggested that advanced maternal age is associated with placental dysfunction that may increase the risk of stillbirths (18) or to existing maternal medical condition (19). Nevertheless, of the existed evidence, the lack of relationship in this study between advanced maternal age and risk of stillbirth may be explained by the low percentage of mothers of advanced age in our sample.
Based on the WHO ICD-PM classification, the main two contributing fetal conditions of antepartum stillbirth in this study were antepartum death of unspecified cause and acute antepartum event (hypoxia), followed by congenital malformations and chromosomal abnormalities. Allanson et al. (20) have demonstrated the application of the WHO ICD-PM to perinatal deaths in two data sets from UK and South Africa. Similar to our findings, they reported antepartum hypoxia events as the major causes of antepartum deaths for the South Africa data set. Maternal conditions that were associated with these deaths were mostly medical and surgical conditions. For the UK data set, the majority of antepartum deaths were unexplained deaths to healthy mothers. Antepartum hypoxia is one of the most significant problems that contribute to stillbirths and neonatal deaths and can be caused by many conditions such as placental insufficiency (21).
Congenital malformation was reported constantly across many classification systems (6), which could be preventable by prenatal folic acid supplements that is proved to decrease the incidence of congenital abnormalities such as neural tube defects (22).
Complications of placental cord and membranes was identified as the main contributing maternal condition of stillbirth in our study. Previous studies showed that a significant percentage of stillbirths arises from placental problems (16,23). Because of the inadequate oxygen supply to the fetus, placental dysfunction is linked to intrauterine growth restriction, preterm birth, and birth defects (24), which significantly increase the perinatal mortality and morbidity. This explains why preterm birth and low birth weight are the main contributing factors of stillbirths.
Intrapartum stillbirths were relatively few in our study, however, they were significant in highlighting a very important contributing conditions of stillbirth. Fetal contributing conditions of the intrapartum stillbirths included congenital malformations deformations and chromosomal abnormalities, other specified intrapartum disorder, intrapartum death of unspecified cause. Maternal contributing conditions of intrapartum stillbirths included complications of placental cord and membranes. The majority of these deaths could be prevented with reasonably priced interventions (25). Bhutta and others proposed a basic package of antenatal interventions to reduce the incidence of antepartum and intrapartum stillbirths. The package includes periconceptional folic acid supplement, prevention of malaria, detection and management of syphilis during pregnancy, and basic and comprehensive emergency obstetric care (26). Other interventions may include testing of high-risk pregnancies, ultrasonographic monitoring, and iatrogeneic deliveries (27). As there is no clear evidence that ultrasonographic monitoring is harmful during pregnancy (28), it could be used with high risk pregnancies for the many presumed benefits of it, including better estimation of gestational age, earlier detection of multiple pregnancies, placental abnormalities, fetal malformation and intrauterine fetal growth restriction (28).
The antepartum stillbirths reflect the quality that women receive during the antenatal period, while the intrapartum stillbirths reflect the quality of care that they receive during delivery (29). The WHO has reported that deficiencies in the quality of antenatal care play significant role in increasing stillbirth rate (30). Research has documented a significant decrease in stillbirths with higher quality antenatal care, women education, and regular antenatal visits, and recommended more involvements of the health care provider in teaching mothers about the danger signs of pregnancy rather providing only the basic health care assessments such as measuring their blood pressure (31).
Maternal mortality and stillbirth are strongly correlated. It is imperative, therefore, to increase our attention for stillbirths and preterm birth interventions, which will positively impact on the maternal and newborn health outcomes (32). Investing in the health care system and providing a good quality and timely maternal services may prevent significant ratio of stillbirths (33).
In interpretation of the study findings, one should consider that the study of specific causes of stillbirth has been hampered by lack of investigations such as fetal autopsy and genetic evaluation.