This analysis of the factors linked with stillbirth among deliveries in sub-Saharan Africa revealed three main characteristics, utilizing six (6) databases and one additional source. Studies included data from a variety of observational study designs, including cross-sectional, cohort, case-control, and unspecified descriptive studies. Based on the results of primary investigations, the current study sought to uncover the factors linked to stillbirths among deliveries in sub-Saharan Africa. Out of the total 54 variables mentioned, nineteen (19) determinants were analyzed to reveal the relationship between factors and stillbirths. The factors or determinants of stillbirths recorded in the current meta-analysis are divided into three categories: Socio-demographic related factors include maternal age, educational attainment, marital status, and place of residence. Pregnancy-related factors include ANC follow-up, APH, birth weight, gestational age, parity, mode of arrival, sex of the newborn, history of prior stillbirths, mode of delivery, multiple gestations, and PROM. Maternal health-related factors include anemia, diabetes mellitus, HIV sero-status, and hypertension. Among the 19 variables, this meta-analysis identified a highly significant statistical association between 9 variables and stillbirth. Those variables that have a strong statistically significant association with stillbirths include; maternal age, educational attainment, ANC, APH, BW, mode of arrival, history of previous stillbirths, anemia, and hypertension.
Regarding socio-demographic factors, the result of this study explained that stillbirth occurred at a significantly higher rate in women over 35 years than in those between 20 and 35 years. This result is in line with research from Ethiopia (6), (7), Cameroon (1), and Ghana (4). The reason for this discrepancy may be explained by the fact that, as a mother's age increases, she is more likely to have aberrant chromosomes and to have developed health issues that can also impair the health of the fetus. Thus, congenital or chromosomal problems may be the reason for stillbirths in women 35 years of age or older. Moreover, the level of education was a determinant in stillbirths. Compared to women who had no formal education, the stillbirth rate was significantly lower among mothers with primary and higher levels of education. This result is consistent with research from Ethiopia (2), (8). The fact that mothers with higher levels of education understand contraception, prenatal care, risk factors, and complications that may arise during pregnancy and delivery. This may help to explain the stark difference between mothers with no formal education and those with primary and higher levels of education. Hence, we must put in a lot of effort and promote women's emancipation and education in order to lower stillbirths in sub-Saharan Africa. The marital status of the mother has a mild association with stillbirth. Compared to mothers of singletons, married women had a lower risk of stillbirth. This result is consistent with several stillbirth investigations (7) (30), (32), (33). This might be the case since married women tend to have stronger social networks of families and friends than singletons. This result contradicts other studies (15), (23), (25). In addition, mothers who resided in rural locations were more likely to experience stillbirth than mothers who lived in urban areas. This study was supported by the studies done in Ethiopia (5), (7), (9). This may be because women who live in rural areas may have difficulty getting to medical facilities. The studies in Cameroon (17) and Nigeria (13) showed no difference between rural and urban residence.
In this meta-analysis, 11 factors were studied in relation to pregnancy-related features; five of them had a direct relationship with mothers, and six had a direct relationship with the fetus. When it comes to mother-related factors, the results of the study revealed a significant relationship between ANC follow-up and stillbirth. This result is consistent with several stillbirth investigations (6), (7), (12). This may be because stillbirth rates were higher in groups that received inadequate antenatal care, went to fewer than four appointments, and had fewer visits overall. In addition to offering vitamins and prevention, ANC may be very beneficial for early problem diagnosis and management. Additionally, according to these studies, primiparity was negatively associated with stillbirth. This finding is at odds with earlier research from Ghana (4), (21), (22), but it is supported by research from Cameroon (18) and Tanzania (28). Another factor that was substantially associated with stillbirth was the mode of arrival. Compared to women who arrived from their homes, mothers who came on a referral were more likely to experience stillbirth. This result is consistent with several stillbirth investigations (4), (7), (14), (28). This may be because pregnant women are frequently referred to a nearby higher health institution after staying longer at their local health facility. They might therefore have acquired difficulties before they arrived at the higher institution. Another factor that was strongly linked to stillbirth was the history of past stillbirths. In comparison to mothers who had no history of previous loss, those who had a history of stillbirth in the previous pregnancy were more likely to experience it in the present pregnancy. This result is consistent with a number of stillbirth investigations (3), (9), (16), (23). This may be because women who have experienced stillbirth before are more likely to experience other unfavorable pregnancy outcomes, such as preterm birth, low birth weight, and placental abruption, which may result in stillbirth. Another factor linked to stillbirth was the mode of delivery. Compared to vaginal birthing mothers, mothers who gave birth via C/S had a decreased chance of stillbirth. This result is consistent with stillbirth investigations conducted in Ghana (12), and Ethiopia (3), (7). This could be a result of the fact that C/S delivery aims to reduce problems for both the mother and the infant. Hence, if C/S is performed with the proper indication, the risk of stillbirth from lengthy labor and fetal discomfort will be reduced. This result conflicts with findings from other studies conducted in Ethiopia (32) and Ghana (37).
When it comes to fetal-related factors, this meta-analysis revealed that mothers who experienced antepartum hemorrhage were more likely to give birth to stillborn children than mothers who did not. This result is consistent with numerous stillbirth studies (1), (6), (7), (18). This may be because antepartum bleeding, whether it originates from the mother or the placenta, can cause fetal compromise and fetal mortality. If this is not handled right away, a stillbirth will occur. In addition to that, lower birth weight was found to be substantially associated with stillbirth in this meta-analysis. Previous research from Uganda (30), and Ghana (4), (21), (22) lends credence to this conclusion. This could be a result of the newborn's higher risk of health hazards and intrapartum complications associated with low birth weight. Nonetheless, this meta-analysis found that, compared to term pregnancies, preterm deliveries had increased risk of stillbirth. Previous research from Ethiopia (5), Cameroon (1), and Ghana (21) lends support to this conclusion. This might be because having a labor early increases the likelihood that the child will experience major health issues, including the risk of congenital infections and passing away. Another variable found in this meta-analysis was newborn sex. This study showed that, compared to female sex, male sex was more likely to experience stillbirth. This result is consistent with various stillbirth investigations in Nigeria (13), Ghana (40), and Cameroon (18). This result conflicts with other studies conducted in Nigeria (24), and Cameroon (18). Another factor related to stillbirth was multiple gestations. Compared to singleton pregnancies, mothers who had multiple gestations were more likely to experience stillbirth. This result is consistent with various stillbirth investigations (1), (5),(9). This may be because there are fundamentally different physiological changes as the number of fetuses’ increases, which causes more complications in multiple gestation than in single gestation. Premature membrane rupture was yet another factor that was linked to stillbirth. Compared to women without PROM, those who had it were more likely to experience stillbirth. This result is consistent with several stillbirth investigations (1), (3), (5),(7). This could be because PROM raises the chance of infection, fetal discomfort, and ultimately fetal loss and stillbirth.
In terms of medical-related factors, we found in our meta-analysis that anemia was strongly linked to stillbirth. Compared to mothers without anemia, those who had anemia were more likely to experience a stillbirth. This result is consistent with numerous stillbirth investigations (1), (2), (12), (25), (29). This could be as a result of the mother's anemia, which can lead to heart failure and decreased cardiac output, both of which can jeopardize the fetus and cause stillbirth.
In addition, this study found that mothers with DM during pregnancy had a higher risk of stillbirth than mothers without DM. This result is consistent with other stillbirth studies (11), (19), (32). This may be because women with diabetes mellitus may experience problems with their metabolism during pregnancy. This puts the mother at risk for both stillbirth and fetal death. HIV sero-status was a further factor that this study revealed. Compared to women who had a negative result, mothers who had a positive result for HIV sero-status had a higher risk of stillbirth. According to various studies on stillbirth (1), (5), (27), this conclusion is consistent. The mother may be more susceptible to opportunistic infections as a result of her immune system being affected by HIV, a systemic disease. This issue caused a fetal infection and resulted in fetal death. In this meta-analysis, we also discovered that women who had hypertension throughout pregnancy had a higher risk of stillbirth than mothers who did not. This result is consistent with other stillbirth studies conducted in Ethiopia (3), (5), (7), Cameroon (1), and Tanzania (29). This may be the outcome of the significant impact that pregnancy-related hypertension has on the circulatory system of the mother, which leads to fetal compromise and fetal mortality.
Limitations and Strengths of the Study
All of the primary articles included in this review had observational study designs, which meant that confounding factors had the potential to alter the outcome variable. The fact that this country-based study only took into account articles written in English was another limiting issue. As almost all of the included countries had low incomes, it is also difficult to extrapolate the results to countries with stronger economic standing. Another restriction was that, due to the variability in the reporting system, several of the variables that were stated in the bulk of the articles were not included. Regarding the study's strength, many stillbirth-related variables were considered in this meta-analysis. The majority of the studies included in this meta-analysis used large sample sizes, which is thought to be one of the factors affecting the study's power. Also, the accompanying articles are of higher quality. The use of a broad search method to find the most articles and the generally high quality of the initial observational research are the other strengths. The relevant research from the many countries included in this meta-analysis reflects several sub-Saharan regions, which increases the likelihood of applicability. Even if limited to observational studies were our limitations, to account for confounding, adjusted results received more attention. To eliminate the limitations we encountered in this study, we advise future studies in this field to incorporate interventional and non-English studies.