Determinants of stillbirths in sub-Saharan Africa: A systematic review

Background: Sub-Saharan African (SSA) countries have high stillbirth rates compared with high-income countries, yet research on risk factors for stillbirth in SSA remain scant. Objectives: To identify the modifiable risk factors of stillbirths in SSA and investigate their strength of association using a systematic review. Search Strategy: CINAHL Plus, EMBASE, Global Health and MEDLINE databases were searched for literature. Selection Criteria: Observational population-and facility-level studies exploring stillbirth risk factors, published in 2013-2019 were included. Data Collection and Analysis: A narrative synthesis of data was undertaken and the potential risk factors were classified into subgroups. Main Results: Thirty-seven studies were included, encompassing 20 264 stillbirths. The risk factors were categorised as: maternal antepartum factors (0-4 antenatal care visits, multiple gestations, hypertension, birth interval of >3 years, history of perinatal death); socio-economic factors (maternal lower wealth index and basic education, advanced maternal age, grand multiparity of >= 5); intrapartum factors (direct obstetric complication); fetal factors (low birthweight and gestational age of <37 weeks) and health systems factors (poor quality of antenatal care, emergency referrals, ill-equipped facility). The proportion of unexplained stillbirths remained very high. No association was found between stillbirths and body mass index, diabetes, distance from the facility or HIV. Conclusions: The overall quality of evidence was low, as many studies were facility based and did not adjust for confounding factors. This review identified preventable risk factors for stillbirth. Focused programmatic strategies to improve antenatal care, emergency obstetric care, maternal perinatal education, referral and outreach systems, and birth attendant training should be developed. More population-based, high-quality research is needed.