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      Effect of Socioeconomic Deprivation and Health Service Utilisation on Antepartum and Intrapartum Stillbirth: Population Cohort Study from Rural Ghana

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          Abstract

          Background

          No studies have examined the effect of socioeconomic deprivation on antepartum and intrapartum stillbirths in the poorest women in low income countries.

          Methodology/ Principal Findings

          This study used data from a prospective population based surveillance system involving all women of childbearing age and their babies in rural Ghana. The primary objective was to evaluate associations between household wealth and risk of antepartum and intrapartum stillbirth. The secondary objective was to assess whether any differences in risk were mediated by utilisation of health services during pregnancy. Data were analysed using multivariable logistic regression. Random effect models adjusted for clustering of women who delivered more than one infant. There were 80267 babies delivered from 1 July 2003 to 30 September 2008: 77666 live births and 2601 stillbirths. Of the stillbirths 1367 (52.6%) were antepartum, 989 (38.0%) were intrapartum and 245 (9.4%) had no data on the timing of death. 94.8% of the babies born in the study (76129/80267) had complete data on all covariates and outcomes. 36 878 (48.4%) of babies were born to women in the two poorest quintiles and 3697 (4.9%) had no pregnancy care. There was no association between wealth and antepartum stillbirths. There was a marked ‘dose response’ of increasing risk of intrapartum stillbirth with increasing levels of socioeconomic deprivation (adjOR 1.09 [1.03–1.16] p value 0.002). Women in the poorest two quintiles had greater risk of intrapartum stillbirth (adjOR 1.19 [1.02–1.38] p value 0.023) compared to the richest women. Adjusting for heath service utilisation and other variables did not alter results.

          Conclusions/ Significance

          Poor women had a high risk of intrapartum stillbirth and this risk was not influenced by health service utilisation. Health system strengthening is required to meet the needs of poor women in our study population.

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          Most cited references15

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          The inverse care law.

          J T Hart (1971)
          Article 0 comments Cited 167 times – based on 0 reviews     Review now
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            Maternal health in poor countries: the broader context and a call for action.

            Veronique Filippi, Carine Ronsmans, Oona Campbell … (2006)
            In this paper, we take a broad perspective on maternal health and place it in its wider context. We draw attention to the economic and social vulnerability of pregnant women, and stress the importance of concomitant broader strategies, including poverty reduction and women's empowerment. We also consider outcomes beyond mortality, in particular, near-misses and long-term sequelae, and the implications of the close association between the mother, the fetus, and the child. We make links to a range of global survival initiatives, particularly neonatal health, HIV, and malaria, and to reproductive health. Finally, after examining the political and financial context, we call for action. The need for strategic vision, financial resources, human resources, and information are discussed.
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              Stillbirth in developing countries: a review of causes, risk factors and prevention strategies.

              Omrana Pasha, Zoë E. McClure, Robert L Goldenberg … (2009)
              To understand the rates, causes and risk factors for stillbirth in developing countries as well as the strategies that have been evaluated to reduce stillbirth. We searched the English literature for 2003-2008 for all articles related to stillbirth and perinatal mortality in developing countries and reviewed all related publications. Despite the large number of stillbirths worldwide, the topic of stillbirths in developing countries has received very little research, programmatic or policy attention. In many developing countries, almost half of the deliveries occur at home, and under-reporting of stillbirths is a significant problem. Reliable data about rates and causes are unavailable in many areas of the world. Nevertheless, of the estimated 3.2 million stillbirths that occur yearly world-wide, the vast majority occur in developing countries. Rates in many developing countries are 10-fold greater or more than in developed countries. There is not a standard international classification system that defines cause of death, nor is there agreement about the lower limits of birthweight or gestational age that define stillbirth, making comparisons of causes of stillbirth or rates over time or between sites problematic. From available data, prolonged and obstructed labour, pre-eclampsia and various infections, all without adequate treatment, appear to account for the majority of stillbirths in developing countries. Identification and treatment of maternal syphilis has been effective in reducing stillbirth risk, as has improvements in access to emergency obstetrical services and particularly caesarean section. Further research is needed to understand the causes and the best preventive strategies for stillbirth specific to geographic areas. However, based on current data, better access to appropriate obstetric care, particularly during labour and delivery and better screening and treatment of syphilis should reduce developing country stillbirth rates dramatically.
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                Author and article information

                Contributors
                : Role: Editor
                Journal
                Journal ID (nlm-ta): PLoS One
                Journal ID (iso-abbrev): PLoS ONE
                Journal ID (publisher-id): plos
                Journal ID (pmc): plosone
                Title: PLoS ONE
                Publisher: Public Library of Science (San Francisco, USA )
                ISSN (Electronic): 1932-6203
                Publication date Collection: 2012
                Publication date (Electronic): 13 July 2012
                Volume: 7
                Issue: 7
                Electronic Location Identifier: e39050
                Affiliations
                [1 ]Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
                [2 ]Kintampo Health Research Centre, Kintampo, Brong Ahafo, Ghana
                [3 ]School of Paediatrics and Child Health, University of Western Australia, Perth, Western Australia, Australia
                University of Cape Town, South Africa
                Author notes

                Conceived and designed the experiments: KE YH LH. Performed the experiments: KE LH YH CT BK. Analyzed the data: LH YH. Contributed reagents/materials/analysis tools: LH. Wrote the paper KE YH.

                Article
                Publisher ID: PONE-D-12-03408
                DOI: 10.1371/journal.pone.0039050
                PMC ID: 3396614
                PubMed ID: 22808025
                SO-VID: c0aa7406-8b27-4361-a4b3-28f223398540
                Copyright © Ha et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
                History
                Date received : 1 February 2012
                Date accepted : 17 May 2012
                Page count
                Pages: 8
                Categories
                Subject: Research Article
                Subject: Medicine
                Subject: Clinical Research Design
                Subject: Cohort Studies
                Subject: Epidemiology
                Subject: Pediatric Epidemiology
                Subject: Non-Clinical Medicine
                Subject: Health Care Policy
                Subject: Health Systems Strengthening
                Subject: Health Care Quality
                Subject: Health Economics
                Subject: Obstetrics and Gynecology
                Subject: Pregnancy
                Subject: Pregnancy Complications
                Subject: Labor and Delivery
                Subject: Pediatrics
                Subject: Neonatology
                Subject: Public Health
                Subject: Child Health
                Subject: Socioeconomic Aspects of Health
                Subject: Women's Health

                ScienceOpen disciplines: Uncategorized
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                ScienceOpen disciplines: Uncategorized

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