Stillbirth risk by fetal size among 126.5 million births in 15 countries from 2000 to 2020: A fetuses‐at‐risk approach

Author:

Okwaraji Yemisrach B.1ORCID,Suárez‐Idueta Lorena2,Ohuma Eric O.1,Bradley Ellen1,Yargawa Judith1,Pingray Veronica3ORCID,Cormick Gabriela34,Gordon Adrienne5,Flenady Vicki6,Horváth‐Puhó Erzsébet7,Sørensen Henrik Toft7,Abuladze Liili8,Heidarzadeh Mohammed9,Khalili Narjes10ORCID,Yunis Khalid A.11,Al Bizri Ayah11,Barranco Arturo12,van Dijk Aimée E.13,Broeders Lisa13,Alyafei Fawzya14,Olukade Tawa O.14,Razaz Neda15,Söderling Jonas15,Smith Lucy K.16,Matthews Ruth J.16,Wood Rachael1718,Monteath Kirsten19,Pereyra Isabel2021,Pravia Gabriella21,Lisonkova Sarka22,Wen Qi22,Lawn Joy E.1,Blencowe Hannah1ORCID,

Affiliation:

1. Maternal, Adolescent, Reproductive and Child Health (MARCH) Centre London School of Hygiene & Tropical Medicine London UK

2. Mexican Society of Public Health Mexico City Mexico

3. Institute for Clinical Effectiveness and Health Policy Ciudad Autónoma de Buenos Aires Buenos Aires Argentina

4. Universidad Nacional de la Matanza San Justo, Buenos Aires Argentina

5. Faculty of Medicine and Health University of Sydney Sydney New South Wales Australia

6. Centre of Research Excellence in Stillbirth, Mater Research Institute The University of Queensland (MRI‐UQ) Brisbane Queensland Australia

7. Department of Clinical Epidemiology Aarhus University and Aarhus University Hospital Aarhus Denmark

8. Estonian Institute for Population Studies, School of Governance, Law and Society Tallinn University Tallinn Estonia

9. Paediatrics Department Alzahra Hospital Iran Tabriz Iran

10. Preventive Medicine and Public Health Research Centre, School of Medicine Iran University of Medical Sciences Tehran Iran

11. The National Collaborative Perinatal Neonatal Network (NCPNN) Coordinating Center at the Department of Paediatrics and Adolescent Medicine American University of Beirut Beirut Lebanon

12. Directorate of Health Information Ministry of Health Mexico City Mexico

13. Perined Utrecht the Netherlands

14. Hamad General Hospital Doha Qatar

15. Clinical Epidemiology Division, Department of Medicine Solna Karolinska Institute Stockholm Sweden

16. Department of Population Health Sciences, College of Life Sciences University of Leicester Leicester UK

17. Public Health Scotland Edinburgh UK

18. Usher Institute University of Edinburgh Edinburgh UK

19. Pregnancy, Birth and Child Health Team Public Health Scotland Edinburgh UK

20. Faculty of Health Sciences Catholic University of Maule Talca Chile

21. Catholic University of Uruguay Montevideo Uruguay

22. Department of Obstetrics & Gynaecology University of British Columbia Vancouver Canada

Abstract

AbstractObjectiveTo compare stillbirth rates and risks for small for gestational age (SGA), large for gestational age (LGA) and appropriate for gestational age (AGA) pregnancies at 24–44 completed weeks of gestation using a birth‐based and fetuses‐at‐risk approachs.DesignPopulation‐based, multi‐country study.SettingNational data systems in 15 high‐ and middle‐income countries.PopulationLive births and stillbirths.MethodsA total of 151 country‐years of data, including 126 543 070 births across 15 countries from 2000 to 2020, were compiled. Births were categorised into SGA, AGA and LGA using INTERGROWTH‐21st standards. Gestation‐specific stillbirth rates, with total births as the denominator, and gestation‐specific stillbirth risks, with fetuses still in utero as the denominator, were calculated from 24 to 44 weeks of gestation.Main Outcome MeasuresGestation‐specific stillbirth rates and risks according to size at birth.ResultsThe overall stillbirth rate was 4.22 per 1000 total births (95% CI 4.22–4.23) across all gestations. Applying the birth‐based approach, the stillbirth rates were highest at 24 weeks of gestation, with 621.6 per 1000 total births (95% CI 620.9–622.2) for SGA pregnancies, 298.4 per 1000 total births (95% CI 298.1–298.7) for AGA pregnancies and 338.5 per 1000 total births (95% CI 337.9–339.0) for LGA pregnancies. Applying the fetuses‐at‐risk approach, the gestation‐specific stillbirth risk was highest for SGA pregnancies (1.3–1.4 per 1000 fetuses at risk) prior to 29 weeks of gestation. The risk remained stable between 30 and 34 weeks of gestation, and then increased gradually from 35 weeks of gestation to the highest rate of 8.4 per 1000 fetuses at risk (95% CI 8.3–8.4) at ≥42 weeks of gestation. The stillbirth risk ratio (RR) was consistently high for SGA compared with AGA pregnancies, with the highest RR observed at ≥42 weeks of gestation (RR 9.2, 95% CI 15.2–13.2), and with the lowest RR observed at 24 weeks of gestation (RR 3.1, 95% CI 1.9–4.3). The stillbirth RR was also consistently high for SGA compared with AGA pregnancies across all countries, with national variability ranging from RR 0.70 (95% CI 0.43–0.97) in Mexico to RR 8.6 (95% CI 8.1–9.1) in Uruguay. No increased risk for LGA pregnancies was observed.ConclusionsSmall for gestational age (SGA) was strongly associated with stillbirth risk in this study based on high‐quality data from high‐ and middle‐income countries. The highest RRs were seen in preterm gestations, with two‐thirds of the stillbirths born as preterm births. To advance our understanding of stillbirth, further analyses should be conducted using high‐quality data sets from low‐income settings, particularly those with relatively high rates of SGA.

Funder

Children's Investment Fund Foundation

Publisher

Wiley

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