We identified 67 stillbirths out of the 2,772 births analyzed from the four hospital registers representing 24/1,000 live births, a burden of mortality that is closely comparable to the current national estimate.[3, 7] The stillbirth rate identified at RBF sites was 37/1,000 live births, substantially higher than at the non-RBF sites which recorded 10/1,000 live births.
Intrapartum stillbirth is considered to be a measure of the quality of intrapartum care or may reflect inadequacies in antenatal care. In this study, stillbirth was significantly more common in RBF sites compared to non-RBF sites: this would clearly represent an unintended effect of the financing intervention. According to a study done in Malawi which was exploring intended and unintended effects of PBF, it was found that apart from positive impact of PBF on service delivery, unintended effects may occur owing to implementation realities. These include health system factors such as inadequate human resources to cater for the increased service load induced by the intervention. The observed increase in the number of stillbirths at RBF sites could also have resulted from improved documentation and record keeping which was an emphasis in the RBF program that was absent at non RBF sites. As an illustration, it was more difficult to locate registers at the non RBF sites.
The proportion of FSB (52%) which are intrapartum deaths is higher than that of MSB (48%). These findings are consistent with a study done in southern Africa, with much higher overall stillbirth rates, where 50% or more of the losses were intrapartum. In The Gambia findings were similar and were attributed to non-use of partograph and obstetric complications during intrapartum period. In an evaluation of RBF4MNH impact in the four RBF interventions districts in Malawi, there was no effect observed on the clinical performance of labor monitoring and partograph documentation. The study reported that the proportion of the partograph monitored cases with complete partograph documentation was 52%. This finding justifies the observed trend in the fresh stillbirths as the evaluation showed no effect on intrapartum care which is key to newborn outcomes especially fresh stillbirth, and may discount the possibility that the apparent adverse association could be entirely a result of improved record keeping.
Previous systematic reviews have found that the most common factors associated with stillbirth in low resource countries were the lack of adequate antenatal care, lack of a skilled attendant at delivery, low socio-economic status, poor nutrition, previous stillbirths and advanced maternal age.[17–19] In the RBF4MNH evaluation study, utilization rates for other maternal care services, specifically timely first ANC and at least 4 ANC visits, was found to stagnate at very low levels. In Nigeria, over half (57.0%) of the mothers with stillbirths had no antenatal care. Although evidence supporting a direct and linear relationship between antenatal care and stillbirth is lacking, the increase in proportion of stillbirths in the RBF sites could also be attributed to low ANC utilization as reported in the RBF final results. Antenatal care can potentially serve as a platform to deliver interventions to improve the quality maternal care and early detection of risk factors that may lead to stillbirths. Several factors beyond those explored in this study could also have contributed to the increase in the number of stillbirths in the RBF facilities. These factors include increase in service utilization due to incentives given leading to pressure of work, hence affecting quality of care given to the mother during labour and delivery.
In this study, a majority of the stillbirths were recorded in the mothers aged between 25 to 34 years with the least being recorded in adolescents below the age of 18. Although age did not show any statistical significance and trends, other subgroups have potentially programmatic significance. For example, a study conducted in Ghana reported that the lifetime risk of stillbirth was 40% higher among adolescents as compared to older mothers. Similarly, a multicountry study conducted to describe the pregnancy outcomes among adolescent mothers reported that a high risk of stillbirth was found among all adolescent age groups, but the risk was significant only among adolescent mothers aged 16–17 years. However, the finding of no association of stillbirths with age observed in this study is likely to reflect the small numbers in this group and should not detract from messages that adolescent reproductive health should remain a priority for both national governments and the global health community.
Preterm birth was significantly associated with stillbirth (33%) and this was observed at both RBF and non-RBF sites. A referral hospital based study in Malawi also found preterm birth as a factor associated with stillbirth, and recorded 67% of stillbirths who were preterm. The variations in the reported percentages could be due to the difference in study design and the setting. but overall the link between stillbirth risk and preterm birth is an established one. Thus, increasing attention to interventions to prevent preterm birth and stillbirth, alongside increasing investment for the health and wellbeing of mothers, will accelerate progress for these maternal, fetal, and newborn outcomes.
We found no positive impact of RBF on stillbirth despite the interventions targeting the quality care of for women both antenatally and during labour. In Mozambique, Pakistan, and India, a large study also showed no impact on stillbirth of a very large community intervention.  These programme experiences illustrate how complex a challenge prevention of stillbirth is, as components addressing population-level risk factors and the fine detail of maternity care arrangements across the continuum and especially at the critical time of labour and delivery all need to converge in an effective manner. In some settings the approach has given positive results: in Rwanda where the pay for performance intervention which is similar to RBF there was an increase in utilization and quality of maternal and child care services. In Bangladesh, a pay for performance strategy in MNH improved the volume of services provided although it did not address the quality of care. Generally with RBF, improvements have been observed in terms of increase in the service utilization but to a lesser extent on quality.