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Preventing stillbirths in Africa

More than half of the 2.6 million stillbirths that occur each year happen in Sub-Saharan Africa. Researchers from The University of Manchester are working with healthcare professionals in the region to help prevent stillbirth and improve care.

Not only is stillbirth more common in low-income countries, but the stigma and cultural challenges surrounding bereavement can often mean that women receive very little support and respectful care after their baby dies.

The NIHR Global Health Research Group on Stillbirth Prevention and Management in Sub-Saharan Africa, based at the University, is working with the Lugina Africa Midwives Research Network (LAMRN) to improve outcomes for parents and children in Kenya, Malawi, Uganda, Tanzania, Zambia and Zimbabwe.

Dame Tina Lavender, Professor of Midwifery, is leading the project. She has been working with LAMRN, in Africa for more than 18 years to improve neonatal and maternal care.

"The group is looking at three areas of care”, explains Tina. “The first is about preventing stillbirth and so we are exploring large data sets to identify the main predictors of stillbirth.

“The second is looking at the management of women in labour, in particular looking at the different delays in receiving care that can cause poor outcomes for women and babies.

“And the third is looking at bereavement care; how we can help women who have unfortunately lost their babies and what is the most culturally sensitive way of doing that.”

International collaboration

The partnership brings together LAMRN’s extensive maternity care experience in low-income countries with leading stillbirth prevention research from across the UK, where the stillbirth rate is less than five per thousand live births.

Professor Angela Chimwaza from the University of Malawi is Chair of LAMRN. She says: “In our region, there are around 22 stillbirths per thousand births, which is quite high. The number of stillbirths here is unacceptable when you compare it to the UK.”

“Across the six countries that LAMRN works in, we have very similar problems related to mothers and their health. Some of the factors which are causing these stillbirths can be prevented. We’re monitoring the antenatal and maternal treatment of mothers, ensuring that they receive the right standard of care and identifying areas for improvement. That is going to inform policy, which is the most important thing.”

“We’re looking at the issues preventing women from accessing the correct treatment in the correct place at the correct time.”

Training

Training and capacity development are absolutely integral to this project according to Dr Tracey Mills, who is the group’s training lead.

“We’re constantly identifying new areas for development and trying to assess the training needs, developing new materials and approaches to increase our skills and knowledge in stillbirth prevention”, says Tracey.

The group has produced a number of innovative learning tools, including educational games to support practical skills development for healthcare workers.

“We’ve developed games that are going to improve the learning of both medical and midwifery students”, adds Angela. “They are also good for qualified healthcare professionals”.

“We’ve got the partograph game and the crisis game and we are in the process of developing respectful maternal care game – all of which have to do with improving the quality of care for women and neonates.”

Thanks to the network, more than 600 midwives have already been trained across East Africa with an educational programme designed to improve evidence-based practice and clinical skills.

Low-cost interventions

Part of the group’s work focuses on identifying high-risk pregnancies earlier.

If a woman reports reduced baby movements in the later stages of her pregnancy then it can be an indicator of poor fetal growth. Doctors in high-income countries commonly use this low-cost yet effective intervention, so the group are developing a means by which this method can be adapted and used in countries with fewer resources.

The group’s research also indicates that women who have previously had a stillbirth are more likely to experience complications in subsequent pregnancies.

“We want to examine whether it’s possible to conduct a large-scale research study testing a specialised antenatal clinical service with psychosocial support and preparation for birth for women to improve birth outcomes”, says Dr Rebecca Smyth, Stillbirth Prevention Project Lead for Zimbabwe and Senior Lecturer in Midwifery at The University of Manchester.

“The service will be designed to improve the quality of antenatal care provision, reduce the risk of pregnancy complications, including stillbirth and give women a positive pregnancy experience.”

Social causes of stillbirth

The group is also exploring other factors impacting the birth of a baby, such as accessibility of healthcare services.

“We’re looking at some of the social factors,” says Tina. “For example, how far a woman has to travel from her home to the facility, what kind of transport she’d use to get there and identifying the barriers that would prevent her from attending the facility in the first instance.

“We’re looking at the issues preventing women from accessing the correct treatment in the correct place at the correct time.”

By doing so, the research team plans to develop effective interventions tailored specifically to meet the needs of the patient population in each region.

Zimbabwe health professionals

“We’re interviewing women, their partners and health professionals to see what their perspectives are,” explains Tina. “Although we work with six different countries, we might not end up with the same interventions in each one as there are cultural variabilities and differences that need to be taken into account.”

Respectful care for bereaved parents

The tragedy of stillbirth can have a lasting impact on women and their families, increasing their risk of experiencing depression, anxiety and post-traumatic stress disorder.

The group is working to improve the provision of respectful and culturally sensitive aftercare for bereaved parents.

“The project has a component of social and emotional support for mothers who have experienced a stillbirth delivery,” explains Dr Albert Kihunrwa, lead obstetrician from the LAMRN stakeholder group in Tanzania. 

He says the partnership is working together to “identify the wishes of patients who have endured a stillbirth and to find out what we can do to enhance their recovery, helping them to cope”.

Tina adds: “Due to traditions and beliefs surrounding the issue of stillbirth, it can be a real challenge for women to grieve. We’re looking at how we can implement interventions to make that possible in a way that’s acceptable to women, their partners and the wider communities as well.”