CHAPTER ONE: INTRODUCTION

Background:
According to world health organization (WHO), still birth is a baby born dead at 28

weeks of gestation or more, with a birth weight of ≥1000 g, or a body length of ≥35

cm. The still births may be fresh (death a few hours before delivery) or macerated

(death which occurred many days intra utero before birth) (WHO, 2020). Majority of

these deaths are very devastating to both parents and have been documented to cause

a lot of anxiety, long term depression, post-traumatic stress disorder and

stigmatization especially among the women

Globally, 2.6 million still births occur annually, with more than 7, 178 deaths a day.

The annual global burden of stillbirths is approximately 2.6 million, 98% of which

occur in Sub Saharan Africa. Majority of these deaths are very devastating to both

parents and have been documented to cause a lot of anxiety, long term depression,

post-traumatic stress disorder and stigmatization especially among the women.

Abdusamed Mohammed-Ahmed (2022), found that despite the advancement in

diagnostic tools and autopsy, the cause of a large proportion of stillbirths is not

known. Globally two-thirds to three-quarters of stillbirths may occur during the

antenatal period before labor begins, which are often associated with insults that

occur in-utero during the antenatal period. These stillbirths are due to a variety of

factors including bacterial infection, birth defects especially pulmonary hypoplasia,

maternal diabetes, hypertensive diseases in pregnancy, maternal alcohol

consumption, cigarette smoking, and post term

Pregnancy, abruption placentae, radiation poison, physical trauma, rhesus disease,

umbilical cord accidents and intra uterine growth restriction.

Other associated factors are extreme of maternal age, low socio-economic status,

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poor maternal education, null parity or grand multiparity and previous stillbirth. Intra

partum stillbirths are usually the result of fetal distress and or obstructed labour and

often reflect poor quality of clinical care during labour and at delivery. The potential

contribution of antenatal care and good partographic monitoring during labour will

largely help in detecting these risk factors and prevent stillbirth.

In Kenya, the number of still births continues to be very high compared to other

countries worldwide, where Kenya is ranked at position 42 among 193 countries with

the highest rates of still births globally (WHO, 2019). According to International still

birth alliance Save the Children report on still birth, the total number of births in

Kenya per year is 1,564, (2020), the total number of still births per year is estimated

at 34,130, therefore still births per 1,000 births in Kenya stands at 21.8 which is one

of the highest in the world compared to world average which is 12.5 still births per

1,000 births.

Many studies suggest that majority of these deaths could easily be prevented if their

causes and associated factors which are region specific are known.

In 2020, approximately 5 still births per month occurred in Kapsabet County Referral

Hospital (KCRH) representing a 13.3% increase from 2019, (Kapsabet reproductive

health report (2019/2020). Further according to quarterly infant mortality audit

(2019/2020), more than one third of the still births in the hospital were Fresh still

births. This trend continued to be witnessed in the first quarter of (2021).

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Statement of the Problem:-

Still birth rate is high in many developed and developing countries across the globe,

however, majority of these deaths continue to occur in large proportions especially in

developing countries within Sub Saharan Africa including Kenya (WHO, 2020). Such

deaths could easily be prevented with proper Focused Antenatal Care and skilled birth

attendance (Flenady, Koopmans, Middleton,Frøen, Smith, Gibbons, K.,& Fretts, 2019)

Stillbirth is a significant public health issue and in (2020) Kenya was ranked among the

highest in the world. According to the data from Kenya Demographic and Health

Survey (KDHS), (2020) the country`s stillbirth rate was estimated to be around 22

stillbirths per 1000 total births.

The Kenyan government, along with international agents have been working to

address stillbirths through initiatives to aimed at improving access to antenatal and

obstetric care, promoting skilled birth attendance, increasing awareness about

pregnancy-related risks and enhancing the quality of maternal and neonatal health

care services. Despite all these interventions by the government the stillbirth rates are

still high posing a challenge to the management and a burden to the country.

At Kapsabet County Hospital, the number of stillbirths increased over the last few

years. In the year 2020, approximately 5 still births were recorded per month. This is

found to be a 13.3% increase compared to the previous year (2019) (Kapsabet

reproductive health report 2019/2020). Further according to quarterly infant mortality

audit (2019/2020), more than one third of the still births in the hospital were Fresh

still births. This trend continued to be witnessed in the first quarter of (2021

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Justification:-

Despite the large number of stillbirths worldwide, the causes of stillbirths in

developing countries received very little research, programmatic or policy attention

(Di Mario & Lincentto, 2019). The rate of still birth in developing countries

continues to be tenfold greater or more than in developed countries increasing infant

mortality, yet these deaths are easily preventable (WHO, 2020).

The aim of the study is to identify the possible causes of stillbirths as recorded in the

medical records, developing recommendations on evidenced based ways of preventing

still births among pregnant women giving birth in Kapsabet County Referral Hospital

and the County at large.

OBJECTIVES
Broad Objective:-
To determine the factors associated with stillbirth among pregnant women delivering

at Kapsabet County Referral Hospital

Specific Objectives:-
1. To find out Antenatal factors associated with stillbirth among pregnant

women delivering at Kapsabet County Referral Hospital

2. To determine the socio demographic characteristics of mothers affected with still

births at Kapsabet County Referral Hospital.

3. To explore facility related factors associated with stillbirth among pregnant

women delivering at Kapsabet County Referral Hospital

Research Questions:-

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1. What are Antenatal factors associated with stillbirth among pregnant women

delivering at Kapsabet County Referral Hospital?

2. What are the socio demographic characteristics of mothers affected with still

births at Kapsabet County Referral Hospital ?

3. What are the facility related factors associated with stillbirth among pregnant

women delivering at Kapsabet County Referral Hospital?

Scope of the study

The study will be done in a single county and therefore the results cannot be

generalized to the whole population. Since the researcher will administer the

questionnaire, this may have limit the responses given by respondents especially on

sensitive issues such as female genital mutilation.

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CHAPTER 2: LITERATURE REVIEW
Introduction
This chapter presents the review of literature that is relevant to the

topic under investigation as a way to place the study in the context of

the existing body of knowledge as well as to identify the gaps in the

study area which attracts more studies. Karl (2021) and Paul & Criado

(2020) assert that a literature review synthesizes earlier studies to

enhance the foundation of knowledge and offers a thorough overview

of the literature linked to an issue, theory, or approach. The purpose

of the literature review in this chapter was to investigate the most

recent information on the causes of stillbirths.

The loss of a baby late in pregnancy remains too common. Peven et al.

(2021) states that stillbirths continue to be a problem that is frequently

unrecognized and neglected despite the immense burden they place on

women, families, and society. Since most deliveries now take place in

hospitals, regular

Register-recording offers the opportunity to increase stillbirths counting,

albeit there is little research on this occurrence (Peven et al., 2021).

The current study will use data from maternal records to measure

hospital stillbirths

Hug et al. (2021) predicted that the 2 million stillbirths that occurred

globally in 2019 would all happen at 28 weeks or more of pregnancy,

translating to a stillbirth rate of 13.9per 1000 live births globally

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Hug et al. (2021) state that the term "stillbirth" normally refers to a baby

who is born without any indication of life following a specific viability

threshold, with viability typically being determined by gestational age,

birth weight, or length at birth.

Furthermore, Hug et al., (2021) also acknowledges that even in

circumstances in which early ultrasound dating scans are available,

gestational age should be based on the best obstetric estimate to avoid

recall errors

Developing countries have higher rates of stillbirths as compared to developed

countries with significant variations between countries. The rate of stillbirths in

developing countries is 25.5/1000 births with sub-Saharan Africa having the highest

rates.

Antenatal Factors
Antenatal factors associated with still birth refer to various conditions, events and

circumstances that occur during the pregnancy period. Flenady Vet al; (2019)

Antenatal health is a good indicator of both maternal health status in any community.

The need to understand contributory factors is crucial for addressing appropriate

Antenatal health.

2.1.1 Maternal Related Factors to Fresh Still Birth:-

Collaborative research network writing group (2021) established that a history of

mental health problems and diabetes pre-eclampisa and antepartum hemorrhage were

strongly associated with fresh still birth, whereas gestational diabetes mostly associated

with macerated still births.

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Also WHO, (2022) agreed that obstetric and medical factors complicate pregnancy

and hence endanger the life of the fetus during pregnancy. Among these factors,

hypertensive disorders of pregnancy, including preeclampsia, gestational diabetes

hypertension, eclampsia, and/or superimposed preeclampsia/eclampsia were the most

common risk factors which have been associated with stillbirth in many studies, and

diagnosed in 8% of pregnancies but may affect as many as 20% of pregnancies. A

study done in Pakistan22 revealed that a woman with hypertensive disorder of

pregnancy is at much higher risk of developing stillbirth than non-hypertensive

woman. Also stillbirths in the first two pregnancies have common biological causes

beyond any known risk factors of stillbirth that may develop during the second

pregnancy. Women who had previously had a stillbirth were more likely to have

another stillbirth (4.6% vs 1.4%) even though evidence regarding the recurrence of

stillbirth remains controversial. Lema G et al, (2020), found that through unadjusted

odds ratio, it was noted that odds of stillbirths were 22.33 (95% : 15.35–32.50) times

higher for the stillbirths with still birth than the stillbirths with full-term delivery. An

odd of stillbirths for the subjects with congenital anomalies was 11.24 (95% : 6.99–

18.06) times higher than the subjects without congenital anomalies. Also, it was

observed that the odds of stillbirths were 3.01 (95% : 2.03–4.46) times higher for the

subjects with hypertensive disorder than subjects without hypertensive disorder. The

odds of stillbirth were 10.14 (95% : 6.43–15.97), 4.88

(95% : 3.23–7.39), and 21.87 (95% : 15.69–30.48) times higher for the subjects with

abruption, oligohydramnios, and anemia than the subjects without abruption,

oligohydramnios, and anemia, positively.

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Elizabeth M. McClure, (2022), postulates that maternal infections likely are an

important cause of stillbirths, especially in sub-Saharan Africa and south Asia, where

the burden is highest. Due to the lack of routine testing for infection, which can be

complex and often expensive, the prevalence of infection during pregnancy and the

association of many infections with stillbirth are not well-documented, especially in

low-resource countries.

Fetal Factors Associated To Fresh Still Births

Lema G et al, (2020), found that placenta pathologies presented were uteroplacenta

vascular pathology, acute chorioamnionitis, chronic inflammations, coagulation

related lesion, and cord oedema. They further noted that histopathology of selected

few placenta pathological lesions encountered among the cases and control groups

are demonstrated in still birth, hypertensive disorders, anemia, abruption, congenital

malformations, and oligohydramnios were significantly associated with stillbirths.

2.2 Socio-demographic factors

Socio-demographics factors are attribute/characteristics of a population. These traits

may include age, ethnicity, education level, income, occupation among others which

may affect the health outcome of an individual. For the sake of stillbirths, these traits

may increase or decrease vulnerability status of a pregnant woman and thus influence

the pregnancy outcome.

Emma Clarke-Deelder et al, (2022), noted that though advanced maternal age is a

known risk factor for both increased Antenatal morbidity and mortality, the majority

of the stillbirths (140 (82%)) were seen in the women between the age group of 20

and 30 years, similar higher rates were seen in a study conducted by Rajagopal et al.

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Occupation determines the economic status of the family. When women are working

in well-paying jobs they tend to take care of themselves well in terms of diet,

healthy lifestyle, good living conditions, and better medical care among others.

Whereas women who are not employed lack finances to ensure good living

conditions or attaining better medical care due to poverty. Many such women do not

attend antenatal care as well as skilled birth attendants thus predisposing themselves

to instances of undesirable birth outcomes such as stillbirths. A study conducted

among Swedish manual and low-level cushy labourers were 1.5 to multiple times

bound to have a stillbirth than ladies with higher positions

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Facility Related Factors:-
Rajshekher V. Mali et al (2021) found that intrapartum stillbirths are usually the

result of fetal distress and/or obstructed labor, which often reflect poor quality of

clinical care during labor and delivery. The potential contribution of antenatal care

and good partographic monitoring during labor will largely help in detecting these

risk factors and prevent stillbirth.

According to research done in South Africa, there is no significant effect of

gestational age at first ANC visit on stillbirth whereas research conducted in Southern

Nigeria shows that the later the gestational age at first ANC, the higher the fetal

mortality, Abdusamed Mohammed-Ahmed (2022)

Emma Clarke-Deelder et al, (2022) also found that good quality care requires the

provision of evidence-based clinical actions and respectful care by providers. Their

findings showed that labour and delivery care services are lacking in these two

dimensions of quality. They noted that fewer than two-thirds of basic elements of

competent and respectful care were performed.

Emma Clerke-Deelder, et al, (2020) observed that Kenya has had a long history of

decentralisation dating back to the early 1980s, and differences in polies and resource

allocation between regions may explain the variation in quality of care. They found

that individual providers in Malawi appear to give different care to different women.

Younger women and those giving birth for the first time received higher-quality care

than women aged over 35. This finding is particularly concerning given that older

women are at higher risk for complications than the 20–35 age group 28.

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Conclusion
The relevant literature was reviewed and presented appropriately in

this chapter. The literature study emphasized, from a global, sub-

Saharan, and Kenya perspective, the factors associated with

stillbirths. The study thoroughly examined the common causes of

stillbirths, including Antenatal (maternal and fetal), socio

demographic and facility related factors.

Conceptual/Theoretical framework

Antenatal Factors
Maternal
- Antenatal care visits
- Diabetes
-Complications
Fetal
- Cord oedema
-uteroplacenta vascular
pathology
- Chronic inflammations
- Acute chorioamnionitis

Socio demographic Factors Birth Outcome

- Age
- Level of Education • Reduced still births
-Occupation
-Domestic work
- Unemployment

Facility related factors

- Distance
- Health information
-Services at the facility

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CHAPTER THREE: METHODOLOGY

Study Design
This will be a facility based descriptive cross-sectional study design containing

quantitative methods which will be conducted to assess the prevalence and risk

factors to stillbirth among pregnant women delivering at Kapsabet County

Hospital.

Study Area
The study will be carried out at the post natal ward in Kapsabet County Hospital.

The hospital is situated at Kapsabet town, Kapsabet Township of Nandi County.

The hospital has several departments which include outpatient, Laboratory,

Pharmacy, Medical and Surgical wards, Pediatric ward, Gynecological ward, TB

department, Eye and dental clinic, Maternity ward and Maternal and Child

Health Clinic. The reproductive health department (Labor and post natal wards)

will be purposively for carrying out the study because all the mothers after

delivery are discharged through. The post natal wards are fully manned by

qualified, competent, experienced human resource for health of all cadres

consisting of several Medical Officers and midwives who form the bulk of

primary health providers in all facilities.

Study Population
The study population will comprise of all mothers who have fresh still births at

the facility and on average 4 mother shad still births per month at Kapsabet

County Hospital the previous year

Inclusion Criteria
All the mothers affected with still birth at Kapsabet County Referral hospital

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 Clients willing and consented to participate in the study

Exclusion Criteria
Clients who decline to participate in the study

Gestation less 28 weeks

Mothers of steel birth who delivered outside Kapsabet County Referral hospital

Study variables
Independent variable
Independent Variable include:

Antenatal factors associated with still birth which refers to various conditions, events and

circumstances that occur during the pregnancy period e,g diabetes, preeclampsia,

hypertension, placenta pathologies, coagulation related lesion, Socio-demographic factors

Socio-demographics factors are attribute/characteristics of a population. These traits may

include age, ethnicity, education level, income, occupation among others which may affect

the health outcome of an individual. Facility related factors eg, inadequate antenatal care,

insufficient staffing and training, delay access to emergency intervention, inadequate

infection control and hygiene and unavailability of essential equipment’s

Dependent variable
• Reduced still births

Sample size determination

The sample size will be determined using Fisher’s formula; a Sample size of

107 mothers will be recruited for the study.

Sampling Technique
Consecutive sampling method will be used to select the study respondents. Any

mother who will have a fresh still birth at the time of the study and will be willing

to participate in the study will be recruited.

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 Data Collection Tools
Data will be collected using researcher administered structured questionnaires.

The questionnaires will have 3 parts, i.e. Prenatal factors (maternal factors, fetal

factors,) socio- demographic factors and facility related factors contributing to

freshstillbirths.

Pretesting of the Study Tool:

A pre-test of the tool will be done in Kabiyet Sub County Referral hospital. This

will be to determine the validity and reliability of the tool. Pretesting also will help

the researcher to modify the study tool to be able to capture all the information that

will help answer the research questions and meet the study objective. Ten percent

(10%) of the sample size of 40, which will be approximately 4 mothers, will be

recruited for pretesting.

3.8 Validity
The instruments will ensure that it covers all the aspects of the construct being measured it will
also measure the intended theoretical concept

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Reliability of the Data
All the study respondents will be assigned a respondent identification number

(RID. All paper research records will be secured in a lockable filling cabinet. Data

entry, cleaning and validation will be performed in order to achieve a clean data.

Soft copies of the data collected will be password protected

Data Analysis and Presentation

Data entry and statistical analysis will be performed using Statistical Package for

Social Sciences (SPSS) version 23. Descriptive statistics will be analyzed where

measures of central tendency like mean mode and median will be calculated.

The results will be presented using tables, bar graphs and pie charts.

Ethical Considerations

The three ethical principles; Beneficence, Autonomy and Justice will be upheld.

This research will be carried out in accordance with the basic principles defined

in Guidance for Good Clinical Practice and the Principles enunciated in the

Declaration

Data Dissemination and Utilization

Research findings will be disseminated to the hospital management through a

report. The findings will be also presented in conferences and publication in

peer re

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from:
https://www.who.int/maternal_child_adolescent/topics/maternal/maternal_perinat
al/en/.
2. Abdusamed Mohammed-Ahmed, (2022)
https://www.europeanjournalofmidwifery.eu/Author-Abdusamed-
Mohammed- Ahmed/201884
3. De Bernis L, Kinney MV, Stones W, et al. Stillbirths: ending preventable
deaths by 2030. Lancet.2016; 387(10019):703–716. 2
4. WHO, (Stillbirth. https://www.who.int/health-topics/stillbirth#tab= tab_1.
Accessed May 6, 2022.
5. UNICEF. A neglected tragedy: the global burden of stillbirths 2020. Unicef; 2020
6. Abebe H, Shitu S, Workye H, Mose A. Predictors of stillbirth among women who
had given birth in Southern Ethiopia, 2020: A case-control study. PLoS One.
2021;16(5):e0249865. doi:10.1371/journal.pone.0249865
7. Mengesha S, Dangisso MH. Burden of stillbirths and associated factors in
Yirgalem Hospital, Southern Ethiopia: a facility based cross-sectional study. BMC
Pregnancy Childbirth. 2020;20(1):591. doi:10.1186/s12884-020-03296-
8. Flenady, Koopmans, Middleton,Frøen, Smith, Gibbons, K.,& Fretts, 2019
9. Di Mario & Lincentto, 2019).
10. Peven et al.
(2021) Hug et al.,
Lema G et al, (2020),
Elizabeth M. McClure, (2022),
Emma Clarke-Deelder et al,
(2022), Rajshekher V. Mali et al

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