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\begin{document}

\title{Preventable stillbirth in the Solomon Islands -- a retrospective review}



\author[1]{Manarangi De Silva}%
\author[2]{Leeanne Panisi}%
\author[3]{Lenin Manubuasa}%
\author[2]{Catherine Honimae}%
\author[4]{Susan Taragwanu}%
\author[5]{Simon Burggraaf}%
\author[6]{Divinal Ogaoga}%
\author[7]{Anthea Lindquist}%
\author[7]{Susan Walker}%
\author[7]{Stephen Tong}%
\author[8]{Roxanne Hastie}%
\affil[1]{University of Melbourne }%
\affil[2]{National Referral Hospital }%
\affil[3]{National Referral Hospital}%
\affil[4]{Ministry of Health Solomon Islands}%
\affil[5]{World Health Organisation }%
\affil[6]{Ministry of Health Solomon Islands }%
\affil[7]{University of Melbourne}%
\affil[8]{University of Melbourne, Mercy Hospital for Women}%


\vspace{-1em}



  
  \date{May 18, 2024}


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\selectlanguage{english}
\begin{abstract}
Introduction: Stillbirth is a significant global public health issue,
with approximately 98\% occurring in low- and middle-income countries.
The Solomon Islands is a Pacific nation with poor perinatal outcomes and
very little previous research investigating stillbirth. Methods: We
conducted a retrospective cohort study investigating all stillbirths at
the National Referral Hospital in Honiara, Solomon Islands, between
January 2017 and December 2018. Causes of stillbirth and risk factors
were classified on review of available case files. Results: Over two
years, there were 341 stillbirths and 11,056 total births at the
National Referral Hospital (30.8 stillbirths per 1000 births). Cause of
death was documented for 198 and 142 full case files were available.
Most stillbirths occurred antenatally (n=170/198) and 62\% were at
preterm gestations (\textless{}37 weeks). Low birthweight
(\textless{}2500g) was present in 59\% (n=84/142) and preventable
maternal conditions, including hypertensive disorders and syphilis, were
present in 42\% (n=59/142) of cases. Acute events caused 46\% of
intrapartum deaths and 92\% of these had inadequate intrapartum
monitoring. Conclusion: Our study is the first to investigate causes of
stillbirth in the Solomon Islands. We found a large proportion of
preventable stillbirths and significant gaps in documentation. This
highlights the importance and feasibility of a national registry. There
is an urgent need for targeted training in data collection, improved
quality of antenatal and intrapartum care and community awareness to
reduce preventable stillbirths in the Asia-Pacific.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Stillbirth is a significant global public health issue, with an
estimated 2.6 million women affected every year.
\textsuperscript{1-3}Approximately 98\% of stillbirths occur in low-and
middle-income countries (LMICs), with this burden most heavily felt in
South-Asian and African countries. \textsuperscript{2-5} Many
stillbirths in LMICs are thought to be preventable. Despite this, little
progress has been made in reducing these numbers compared to other
perinatal outcomes.

The Solomon Islands is a Pacific LMIC with a population of approximately
700,000, spanning across 993 islands. The country faces significant
geographical, socioeconomic and cultural barriers to achieving health
equity. The National Referral Hospital, situated on the main island of
Guadalcanal, is the only tertiary hospital in the country. Despite this,
there are limited midwifery staff, only 4 consultant obstetricians and
just one or two working cardiotocograph machines at any given time. Like
many of its counterparts in the Asia-Pacific, the Solomon Islands has
poor perinatal outcomes, with a recent study showing a high rate of
preventable maternal mortality\textsuperscript{6} and an estimated
stillbirth rate of 17.6 per 1000 births in 2015 from World Health
Organization data. \textsuperscript{7} In contrast, the rate of
stillbirth in Australia, one of the nation's closest neighbours, has a
stillbirth rate of 6.8 per 1000 births. \textsuperscript{8} Despite
this, there has been little research into improving perinatal outcomes,
and in particular, no previous targeted research investigating causes of
stillbirth in the Solomon Islands.

In order to reduce the global burden of stillbirths, accurate recording
of cause of death and preventable risk factors is required. This could
help direct where to place scarce resources to have maximal impact in
reducing rates of stillbirth. However, in many LMICs this is a
significant challenge due to a lack of health worker training and
diagnostic tools. \textsuperscript{9} Furthermore, many countries do not
have a national registration system for perinatal deaths, particularly
in the Asia-Pacific region. \textsuperscript{2, 10} While there is also
no national registry or classification of stillbirths in the Solomon
Islands, they are audited at National Referral Hospital. This recording
of cases creates an opportunity to investigate the causes of stillbirth
and identify those that may be preventable, as well as identifying gaps
in information with the current data collection system. Such an
investigation would assist in directing scarce resources towards the
most effective clinical service with the aim of ultimately reducing
stillbirth in the Solomon Islands and other similar Pacific Island
nations. Thus, we undertook a retrospective cohort study investigating
the incidence of stillbirth and associated risk factors in the Solomon
Islands.



\textbf{Methods}

We conducted a retrospective cohort study investigating all stillbirths
recorded at the National Referral Hospital in Honiara, Solomon Islands,
between January 2017 and December 2018. Ethical approval was obtained
from the Solomon Islands Ministry of Health and Medical Services Ethics
Board (HRE032/18).

Stillbirth was defined as the death of a fetus before birth
at\(\geq\)20 estimated gestational weeks, or greater than 500g
in birthweight. Antepartum stillbirth was defined as a death occurring
before the onset of labour or ``macerated'' in appearance. Intrapartum
death was considered a death occurring after the onset of labour or
during birth which had a ``fresh'' appearance. Neonates were weighed at
birth and fetal weight cut-offs of \textless{}2500g and \textless{}1500g
were used to define low birth weight and extremely low birth weight,
respectively, as gestational uncertainty decreased the accuracy of
gestational centiles. The total numbers of live births and stillbirths
during the study period were obtained from an existing hospital birth
registry. Where available, case files were reviewed for details
regarding maternal risk factors, contributing factors, sociodemographic
and pregnancy details.

Available case files were reviewed for suspected cause of death and
contributing maternal conditions identified. In the Solomon Islands
verbal autopsy or detailed diagnostic tests are not available to confirm
cause of death. Deaths were deemed preventable if they were over 28
weeks estimated gestation, above 1500g birth weight and excluding those
with congenital anomalies.

There are several international classification systems that aim to
accurately determine the primary cause of stillbirths and risk factors
that may inform public health and policy
interventions.\textsuperscript{11} In 2016 the World Health Organization
(WHO) developed the tenth revision of the International Classification
of Diseases (ICD-10) and applied it to the perinatal period
(ICD-PM).\textsuperscript{11, 12} The ICD-PM first identifies the timing
of perinatal death (antepartum, intrapartum or unknown), then the
assigns the main cause of death, and links each stillbirth with the main
maternal condition contributing to the stillbirth (Table S1 in
appendix). In this study, we used the ICD-PM to classify causes of
stillbirth at the National Referral Hospital. Given there was no
comparison group, descriptive statistics were used to describe the data.
Statistical analyses were performed using STATS 15-IC.

\textbf{Role of the funding source}

The funders had no role in the study design, data collection, data
analysis, data interpretation, or writing of the report. MD and RH had
full access to all the data in the study and had final responsibility
for the decision to submit for publication.



\textbf{Results}

Over two years, 341 stillbirths were documented at the National Referral
Hospital. During the same period, there were 11,056 live births, giving
an institutional incidence of stillbirth of 30.8 per 1,000 births. Of
341 recorded cases, suspected cause of death was available for 198 and
142 maternal full case files were available for full review (Table 1).
Among the 142 case files available, 72\% were thought to be preventable
and there were five associated cases of maternal death.

\textbf{Characteristics of the study population and care}

Women who experienced a stillbirth had a median age of 28 years (IQR
11), 62\% were multiparous and 9\% grand-multiparous ([?] 5 five prior
births). 79\% were married or co-habiting and 73\% had at least a
primary school-level of education, with 40\% having a secondary school
education and only 4\% having no school education. The majority of women
were unemployed or homemakers (67\%), with 28\% either employed or
studying. Most mothers resided on the main island of Guadalcanal (60\%).
29\% of mothers with a stillbirth were referred to the National Referral
Hospital for their care. The majority of stillbirths were delivered by
midwifery or nursing staff (70\%, n=100/142). Prior to discharge, 65\%
of mothers received formal debriefing with local counselling services.

\textbf{The presence of risk factors for stillbirth}

Previously reported and common risk factors for stillbirth were present
within our cohort. 26\% of mothers were anaemic (haemoglobin
\textless{}100 g/L), however, haemoglobin levels were only recorded in
56\% of total cases and information regarding timing of haemoglobin
testing was not available in most records. The median haemoglobin was
108 g/L for these women. 52 women were not tested for syphilis. Of the
90 women who were tested for syphilis, 25\% were positive (n=23/90) and
only seven of these women completed treatment. Only 2 case files had
documentation of partner treatment. Sixteen women (11\%) had experienced
a prior stillbirth. The majority of mothers had at least one antenatal
visit prior to their stillbirth (78\%). 20\% were obese (body mass
index\textgreater{}30), however body mass index was only recorded for
47\% of the cases. All but one mother received an ultrasound during the
course of her care, however only 25\% received an ultrasound in the
first or second trimester. Reduced fetal movements were reported prior
to attendance in 67 cases (47\%). Discussion of common danger signs,
such as reduced fetal movements or vaginal bleeding, were not documented
for 50\% of cases.

Most women had a spontaneous vaginal birth (83\%). There were seven
inductions, two instrumental births and 14 emergency caesarean sections
(two of which were failed inductions). Birthweight was not documented
for 18 stillbirths. Of those with a recorded birthweight, low
birthweight (\textless{}2500g) was present in 59\% of cases, with a
median birthweight of 1920g (range 500g to 4984g, IQR 1668.5g) and 32\%
extremely low birthweight (\textless{}1500g).

\textbf{Time and cause of stillbirth}

The estimated median gestational age of stillbirth was 34 weeks (range
20 to 43 weeks, IQR 9), with 80\% occurring in the third trimester
(n=114/142). The majority (62\%, n=88/142) of stillbirths were preterm
(\textless{}37 completed week gestation), 16\% were \textless{}28 weeks
completed gestation and 4\% were \textgreater{}41 completed weeks
gestation.

Of the 198 stillbirths with a recorded cause of death, 170 occurred
antenatally (86\%) and 28 (14\%) were intrapartum (Table 2). 42\% of
stillbirths were macerated and 31\% were fresh, however appearance of
the fetus at delivery was not documented in 26\% of cases. Table 3.
demonstrates the primary cause of death associated with maternal
conditions, such as maternal complications of pregnancy, labour and
delivery. There were 12 cases (6\%) of congenital malformations, with
the majority being hydrocephalus and one fetus showing signs of Trisomy
21.

\textbf{Antenatal deaths}

Among the antepartum stillbirths, cause of death was unspecified
according to the ICD-PM for 40\% (68/170) of cases (Table 3). Five were
associated with maternal deaths, with three of these secondary to
puerperal sepsis, one secondary to fulminant liver failure and one
secondary to liver and renal failure resulting from severe preeclampsia.
53\% of antenatal stillbirths were not associated with a documented
concurrent maternal condition (Table 3). 25\% (n=43) of cases were
associated with low birthweight and among this group, there was also a
co-existing hypertensive disorder in 28\% of cases (n=12/43). Maternal
infection was present in 19 (11\%) antenatal stillbirths, with 53\%
(n=10/19) of the fetuses showing signs of congenital syphilis. There
were 19 cases of antepartum hypoxia, most of which were associated with
complications of the placenta, cord and membranes (n=12/19), with nine
secondary to placental abruption and the remainder to trauma. Four
deaths were due to termination of pregnancy via maternal use of
misoprostol at between 20 and 37 weeks estimated gestation.

\textbf{Intrapartum deaths}

Of the 28 intrapartum stillbirths, 46\% were due to an acute,
preventable event, such as fetal asphyxia, which was evidenced by
non-reassuring fetal heart rate patterns (where recorded) or loss of
fetal heart rate in labour. Concurrent maternal medical or surgical
conditions were present in three (11\%) cases, with the most common
being hypertensive disorders of pregnancy (n=4). Of these intrapartum
deaths, three had complications of the cord, placenta or membranes (two
with acute cord prolapse), and three were due to extreme prematurity.
Low birthweight was present in five cases and fetal heart rate
monitoring during the second stage of labour was not documented or
performed for the 92\% of cases.



\textbf{Discussion}

\textbf{Main findings}

Our study is the first to investigate the causes of stillbirth in the
Solomon Islands. The incidence of stillbirth at the National Referral
Hospital was 30.8 cases per 1,000 births. This is almost two-fold
greater than the most recent WHO estimate for the Solomon Islands (17.6
per 1000 total births).\textsuperscript{7}

Many stillbirths in LMICs may be prevented through improved antenatal
care.\textsuperscript{3, 13} Whilst most mothers had at least one
antenatal visit, we found significant gaps in the quality of care
received. A third of our cohort were living outside of the main island
and, again, one third were referred for care. This highlights the
challenges of delivering high quality antenatal care in peripheral and
remote settings. Recent global studies have shown that many cases of
stillbirth considered secondary to fetal growth restriction or preterm
birth, in particular, may be preventable through improved antenatal
monitoring and interventions. \textsuperscript{3, 13, 14} Early
ultrasound assessment is vital for dating and diagnosis of potential
fetal growth restriction \textsuperscript{14, 15}, however only 25\% of
mothers received an early ultrasound in our cohort. Of the 85\% of
stillbirths occurring antenatally, suspected growth restriction was
common, with almost 60\% were born at a low birthweight. Over 60\% of
stillbirths occurred at preterm gestations. Of these, 80\% were over 28
weeks gestations and many of these could have been potentially
preventable if there was early detection of the low birthweight. Whilst
access to ultrasound examination is particularly challenging in this
setting, our study has highlighted the potential to reduce stillbirths
if services were expanded.

Routine antenatal testing for syphilis (a major cause of stillbirth
globally. \textsuperscript{2, 3, 16}) is also recommended as part of
antenatal care. A deficiency in testing of syphilis was evident in our
cohort, with 53\% (10 babies) of the 19 antenatal stillbirths associated
with infection showing overt signs of congenital syphilis infection,
however only one third of women were tested. Point of care syphilis
testing is cost-effective and a potential resource in LMICs,
particularly in rural and remote settings where laboratory services are
not readily available. \textsuperscript{16, 17} Once diagnosed, complete
treatment and clearance of syphilis in the woman and partner can
decrease the risk pf stillbirth. However, in the present study only
seven women completed treatment and there was minimal data on partner
testing, which may be attributed to multiple factors, including lack of
penicillin and poor patient and partner understanding.

Education regarding family planning, prevention and danger signs of
pregnancy, such as reduced fetal movements, and birth preparedness are
also vital aspects of antenatal care. However, almost half of the women
within our study did not have documentation regarding discussion of
danger signs during antenatal care. Provided with this information these
women may have presented earlier and some cases may have been prevented.
The late terminations of pregnancy and high parity within our cohort
also point to a significant unmet need for family
planning.\textsuperscript{18} Abortion is illegal in the Solomon
Islands, which highlights the complexity of this issue. This emphasizes
the demand for improved patient and community education and access to
reproductive services to reduce unwanted pregnancy. \textsuperscript{13,
14}

The largest proportion of stillbirths were unclassified (or cause
unknown), which is in keeping with other studies in LMICs and largely
due to lack of diagnostic tools and inadequate
documentation.\textsuperscript{19, 20} We found 14\% of stillbirths
occurred during labour and almost half of these were due to an acute,
preventable intrapartum event. Fetal heart rate monitoring was not
documented in the majority of these stillbirths. Whilst this is
challenging due to limitations in number of healthcare workers, this
highlights the urgent need for improvement in training and provision of
resources to enable safer intrapartum care. Additionally, our
intrapartum stillbirth rate was lower than previous
studies\textsuperscript{1-3, 21}, with a recent study in Timor-Leste
showing an intrapartum stillbirth rate of 33\%.\textsuperscript{21} The
significant number of missing case files may have led to an
underrepresentation of intrapartum deaths. This is certainly plausible
given the majority of intrapartum stillbirths had severe suboptimal
care. This may be also be attributable to inaccurate classification of
some stillbirths as antepartum in those where case files were available,
as a quarter of cases in our study did not have adequate documentation
of maceration. Overall, we found the incidence of stillbirth in the
Solomon Islands to be higher than the average stillbirth rate for its
two closest neighbours, Papua New Guinea and Fiji (rates of 15.9 and
11.9 per 1000 births, respectively).\textsuperscript{7, 21} This may be
due to referral bias; however, the proportional causes of stillbirth are
still likely to reflect the national rate.

Whilst there is much progress to be made, it is promising that some of
the gaps highlighted by our study are being addressed in a recent
updated Antenatal Care Package, launched by The Solomon Islands Ministry
of Health and the World Health Organisation. This package incorporates
focussed health worker education and resource provision, such as
improved access to antenatal ultrasounds and point of care syphilis and
haemoglobin testing. This initiative acknowledges the socioeconomic
return of investing in stillbirths \textsuperscript{2} and is a
fundamental step in reducing the burden of perinatal death in the
Solomon Islands.

\textbf{Strengths and Limitations}

This was the first study investigating causes of stillbirth in the
Solomon Islands. We were also able to successfully apply ICD-PM
classification system to the stillbirths recorded in our study,
demonstrating its potential for utilisation in this setting.

Our study was limited by its retrospective nature and incomplete data.
Second, this study is an underrepresentation of all stillbirths that
occur at a national level as we have only included data from the
hospital-setting and did not include those which within the community or
peripheral centres. Third, the accuracy of gestational age was limited
due to the lack of routine dating ultrasounds. Finally, adequate
registration of stillbirths relies on ascertainment of cause of death,
which remained unspecified in many of our antepartum deaths due to
inadequate and incomplete documentation.

\textbf{Interpretation}

The true magnitude of perinatal deaths remains under-reported and
under-investigated. Similar to many of its Pacific neighbours, The
Solomon Islands currently does not formally register stillbirths. There
is a need to optimise prospective documentation of all birth outcomes
and to adopt classification of all perinatal deaths, in a similar to
maternal deaths through the maternal death surveillance system. The WHO
has recommended verbal autopsy as a tool to assist in determining cause
of perinatal death in LMICs by gathering collateral data from mothers
and clinicians. \textsuperscript{19, 22} This may be utilised to reduce
the number of ``unclassified'' deaths. Whilst many classification
systems have been used in LMICs \textsuperscript{23}, we successfully
utilised the ICD-PM classification system. There is a critical need for
further research and formal classification into why mothers and babies
are suffering in the Solomon Islands and more broadly, in the
Asia-Pacific region. COVID-19 has significantly disrupted health systems
and diverted funding from maternal and child health programs. This is
likely to result in further adverse perinatal outcomes and maternal and
infant death. \textsuperscript{24}

\textbf{Conclusion}

This study revealed a high incidence of stillbirth at the National
Referral Hospital and many cases deemed preventable. Our findings
highlight the urgent need for increased focus on perinatal deaths in the
Solomon Islands with universal classification and targeted training,
improved quality of obstetric care and community awareness. Effective
public health interventions to tackle this preventable global issue can
only be implemented when accurate data are obtained, and thus a national
registry of stillbirths is vital and should be considered region wide.



\textbf{Disclosure of interests}

We declare no competing interests.

\textbf{Contributors}

MD conducted the literature search. MD, LP, RH and LM conceived and
designed this study. MD, LP, CH and S Taragwanu completed data
collection. MD conducted the data analysis and data interpretation and
drafted the of final manuscript and prepared the tables. RH, SW, ST and
AL, SB and DO provided critical analysis and made revisions of the
manuscript and important intellectual contributions. All authors
reviewed the manuscript before final submission.

\textbf{Acknowledgements}

MD was supported by The Royal Australian and New Zealand College of
Obstetricians and Gynaecologists (RANZCOG) Miriam O'Connor Scholarship.
The National Health and Medical Research Council of Australia (NHMRC)
provided salary support to ST (\#1136418), RH (\#1176922), AL and SW. We
are grateful to the Research and Ethics Department and the Reproductive,
Maternal, Newborn and Child and Adolescent Health Division of the
Solomon Islands Ministry of Health, and the Solomon Islands World Health
Organization. Finally, we would like to thank all the midwives, nurses
and doctors at the National Referral Hospital in the Solomon Islands.

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\textbf{Hosted file}

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\textbf{Hosted file}

\verb`Stillbirth Solomon Islands_BJOG supp table final.docx`  available at \url{https://authorea.com/users/470387/articles/562576-preventable-stillbirth-in-the-solomon-islands-a-retrospective-review}

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