Objective. The objective of the study was to assess Plasmodium/intestinal helminth infection in pregnancy and other risk factors for stillbirth in Ghana. Methods. A cross-sectional study of women presenting for delivery in two hospitals was conducted during November-December 2006. Data collected included sociodemographic information, medical and obstetric histories, and anthropometric measures. Laboratory investigations for the presence of Plasmodium falciparum and intestinal helminths, and tests for hemoglobin levels were also performed. Results. The stillbirth rate was relatively high in this population (5%). Most of the stillbirths were fresh and 24% were macerated. When compared to women with no malaria, women with malaria had increased risk of stillbirth ( , 95%？ –9.3). Other factors associated with stillbirth were severe anemia, low serum folate concentration, past induced abortion, and history of stillbirth. Conclusion. The fact that most of the stillbirths were fresh suggests that higher quality intrapartum care could reduce stillbirth rates. 1. Introduction Of the 130 million babies born worldwide every year, approximately 4 million are stillborn [1], more than 98% of these occur in developing countries [2]. Stillbirth accounts for more than half of perinatal mortality in developing countries [3]. In Sub-Saharan Africa, stillbirths account for more than 3% of deliveries each year [2]. While countries in South-East Asia report the highest overall numbers of stillbirth, countries in Africa report the highest incidence rates per 1000 live births [4]. The average stillbirth rate in developing countries has been reported to be 26 per 1000 live births, about five times higher than in developed countries (5 per 1000) [4]. One fourth to one third of all stillbirths is estimated to take place during delivery [5, 6]. Stillbirths occurring in the intrapartum period generally have a normal appearance and are often called “fresh” stillbirths [5]. The skin not being intact implies death more than 24 hours before delivery (antepartum), often called “macerated” stillbirths [5]. Stillbirths have not been widely studied, have been under-reported, and rarely have been considered in attempts to improve birth outcomes in developing countries [5, 6]. There are many factors associated with stillbirth including inadequate access to obstetric care, inadequate care [7], malaria, hypertensive disease, poor nutritional status, history of stillbirth, congenital anomalies, sickle cell disease, and high burden of infectious comorbidities [5, 8–10]. Conceptually, infection
References
[1]
J. E. Lawn, S. Cousens, and J. Zupan, “4 million neonatal deaths. When? Where? Why?” The Lancet, vol. 365, no. 9462, pp. 891–900, 2005.
[2]
C. Stanton, J. E. Lawn, H. Rahman, K. Wilczynska-Ketende, and K. Hill, “Stillbirth rates: delivering estimates in 190 countries,” The Lancet, vol. 367, no. 9521, pp. 1487–1494, 2006.
[3]
S. Cnattingius, B. Haglund, and M. S. Kramer, “Differences in late fetal death rates in association with determinants of small for gestational age fetuses: population based cohort study,” British Medical Journal, vol. 316, no. 7143, pp. 1483–1487, 1998.
[4]
Population Reference Bureau, Evaluating Stillbirths. Improving Stillbirth Data Could Help Make Stillbirths a Visible Public Health Priority, Population Reference Bureau, 2006.
[5]
J. Lawn, K. Shibuya, and C. Stein, “No cry at birth: global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths,” Bulletin of the World Health Organization, vol. 83, no. 6, pp. 409–417, 2005.
[6]
World Health Organization, Neonatal and Perinatal Mortality: Country, Regional and Global Estimates, World Health Organization, Geneva, Switzerland, 2006.
[7]
C. Ronsmans, J. F. Etard, G. Walraven, et al., “Maternal mortality and access to obstetric services in West Africa,” Tropical Medicine and International Health, vol. 8, no. 10, pp. 940–948, 2003.
[8]
E. M. McClure, M. Nalubamba-Phiri, and R. L. Goldenberg, “Stillbirth in developing countries,” International Journal of Gynecology and Obstetrics, vol. 94, no. 2, pp. 82–90, 2006.
[9]
R. L. Goldenberg and C. Thompson, “The infectious origins of stillbirth,” American Journal of Obstetrics and Gynecology, vol. 189, no. 3, pp. 861–873, 2003.
[10]
J. Zupan, “Perinatal mortality in developing countries,” New England Journal of Medicine, vol. 352, no. 20, pp. 2047–2048, 2005.
[11]
R. S. Gibbs, “The origins of stillbirth: infectious diseases,” Seminars in Perinatology, vol. 26, no. 1, pp. 75–78, 2002.
[12]
J. B. Hardy, E. N. Azarowicz, A. Mannini, D. N. Medaris, and R. E. Cooke, “The effect of Asian influenza on the outcome of pregnancy: Baltimore 1957-1958,” American Journal of Public Health, vol. 51, pp. 1182–1188, 1961.
[13]
P. Horn, “Poliomyelitis in pregnancy: a twenty-year report from Los Angeles County, California,” Obstetrics and Gynecology, vol. 6, no. 2, pp. 121–137, 1955.
[14]
R. L. Goldenberg, J. C. Hauth, and W. W. Andrews, “Intrauterine infection and preterm delivery,” The New England Journal of Medicine, vol. 342, pp. 1500–1507, 2003.
[15]
R. W. Steketee, J. J. Wirima, L. Slutsker, D. L. Heymann, and J. G. Breman, “The problem of malaria and malaria control in pregnancy in sub-Saharan Africa,” American Journal of Tropical Medicine and Hygiene, vol. 55, no. 1, pp. 2–7, 1996.
[16]
A. M. Moormann, A. D. Sullivan, R. A. Rochford, et al., “Malaria and pregnancy: placental cytokine expression and its relationship to intrauterine growth retardation,” Journal of Infectious Diseases, vol. 180, no. 6, pp. 1987–1993, 1999.
[17]
E. K. Dorman, C. E. Shulman, J. Kingdom, et al., “Impaired uteroplacental blood flow in pregnancies complicated by falciparum malaria,” Ultrasound in Obstetrics and Gynecology, vol. 19, no. 2, pp. 165–170, 2002.
[18]
R. Ndyomugyenyi, N. Kabatereine, A. Olsen, and P. Magnussen, “Malaria and hookworm infections in relation to haemoglobin and serum ferritin levels in pregnancy in Masindi district, western Uganda,” Transactions of the Royal Society of Tropical Medicine and Hygiene, vol. 102, no. 2, pp. 130–136, 2008.
[19]
L. Drake, Y. Korchev, L. Bashford, et al., “The major secreted product of the whipworm, Trichuris, is a pore-forming protein,” Proceedings of the Royal Society B, vol. 257, no. 1350, pp. 255–261, 1994.
[20]
D. Watson-Jones, H. A. Weiss, J. M. Changalucha, et al., “Adverse birth outcomes in United Republic of Tanzania—impact and prevention of maternal risk factors,” Bulletin of the World Health Organization, vol. 85, no. 1, pp. 9–18, 2007.
[21]
F. E. Viteri, “The consequences of iron deficiency and anemia in pregnancy,” Advances in Experimental Medicine and Biology, vol. 352, pp. 127–139, 1994.
[22]
I. Chanarin, The Megaloblastic Anaemias, Blackwell, London, UK, 1969.
[23]
N. R. de Silva, S. Brooker, P. J. Hotez, A. Montresor, D. Engels, and L. Savioli, “Soil-transmitted helminth infections: updating the global picture,” Trends in Parasitology, vol. 19, no. 12, pp. 547–551, 2003.
[24]
D. H. S. Measures, Demographic Health Survey; Ghana, 2003, Macro International Inc, Calverton, Md, USA, 2004.
[25]
L. A. Ronald, S. L. Kenny, E. Klinkenberg, et al., “Malaria and anaemia among children in two communities of Kumasi, Ghana: a cross-sectional survey,” Malaria Journal, vol. 5, article 105, 2006.
[26]
L. S. Garcia, Diagnostic Medical Parasitology, ASM Press, Washington, DC, USA, 2001.
[27]
J. G. Ayisi, A. M. van Eijk, F. O. ter Kuile, et al., “The effect of dual infection with HIV and malaria on pregnancy outcome in western Kenya,” AIDS, vol. 17, no. 4, pp. 585–594, 2003.
[28]
World Health Organization, Development of Indicators for Monitoring Progress towards Health for All by the Year 2000, Health for All Series, vol. 4, World Health Organization, Geneva, Switzerland, 1981.
[29]
A. M. Tang, N. M. H. Graham, R. K. Chandra, and A. J. Saah, “Low serum vitamin B-12 concentrations are associated with faster human immunodeficiency virus type 1 (HIV-1) disease progression,” Journal of Nutrition, vol. 127, no. 2, pp. 345–351, 1997.
[30]
Department of Reproductive Health Research, World Health Organization, Guidelines Overview Safe Motherhood Needs Assessment, WHO Publication, no. WHO/RHT/MSM/96.18 Rev.1, World Health Organization, Geneva, Switzerland, 2001.
[31]
World Health Organization, Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death Volume I, World Health Organization, Geneva, Switzerland, 1967.
[32]
D. Hosmer and S. Lemeshow, Applied Logistic Regression, Wiley Series in Probability and Statistics, John Wiley & Sons, New York, NY, USA, 2nd edition, 2000.
[33]
S. D. Mario, L. Say, and O. Lincetto, “Risk factors for stillbirth in developing countries: a systemic review of literature,” Sexually Transmitted Diseases, vol. 34, pp. S11–S21, 2007.
[34]
J.-P. van Geertruyden, F. Thomas, A. Erhart, and U. D'Alessandro, “The contribution of malaria in pregnancy to perinatal mortality,” American Journal of Tropical Medicine and Hygiene, vol. 71, no. 2, pp. 35–40, 2004.
[35]
T. W. Gyorkos, R. Larocque, M. Casapia, and E. Gotuzzo, “Lack of risk of adverse birth outcomes after deworming in pregnant women,” Pediatric Infectious Disease Journal, vol. 25, no. 9, pp. 791–794, 2006.
[36]
A. F. Fleming, “Tropical obstetrics and gynaecology. 1. Anaemia in pregnancy in tropical Africa,” Transactions of the Royal Society of Tropical Medicine and Hygiene, vol. 83, no. 4, pp. 441–448, 1989.
[37]
A. F. Fleming, “The etiology of severe malaria in pregnancy in Ndola, Zambia,” Annals of Tropical Medicine and Parasitology, vol. 83, pp. 37–49, 1989.
[38]
P. J. Hotez, S. Brooker, J. M. Bethony, M. E. Bottazzi, A. Loukas, and S. Xiao, “Hookworm infection,” New England Journal of Medicine, vol. 351, no. 8, pp. 799–807, 2004.
[39]
T. W. Mwangi, J. M. Bethony, and S. Brooker, “Malaria and helminth interactions in humans: an epidemiological viewpoint,” Annals of Tropical Medicine and Parasitology, vol. 100, no. 7, pp. 551–570, 2006.
[40]
C. Giles, “An account of 335 cases of megaloblastic anaemia of pregnancy and the puerperium,” Journal of Clinical Pathology, vol. 19, no. 1, pp. 1–11, 1966.
[41]
N. J. Ainley, “Megaloblastic anaemia of pregnancy and the puerperium,” The Journal of Obstetrics and Gynaecology of the British Empire, vol. 68, pp. 254–263, 1961.
[42]
United Nations Secretariat, Population Policy Data Bank, Population Division of the Department for Economic and Social Affairs of the United Nations Secretariat, 1999.
[43]
J. Visintine, V. Berghella, D. Henning, and J. Baxter, “Cervical length for prediction of preterm birth in women with multiple prior induced abortions,” Ultrasound in Obstetrics and Gynecology, vol. 31, no. 2, pp. 198–200, 2008.
[44]
A. Molin, “Risk of damage to the cervix by dilatation for first-trimester-induced abortion by suction aspiration,” Gynecologic and Obstetric Investigation, vol. 35, no. 3, pp. 152–154, 1993.
[45]
S. Cnattingius and O. Stephansson, “The epidemiology of stillbirth,” Seminars in Perinatology, vol. 26, no. 1, pp. 25–30, 2002.
[46]
S. Cnattingius, H. W. Berendes, and M. R. Forman, “Do delayed childbearers face increased risks of adverse pregnancy outcomes after the first birth?” Obstetrics and Gynecology, vol. 81, no. 4, pp. 512–516, 1993.
[47]
A. Samueloff, E. M. J. Xenakis, M. D. Berkus, R. W. Huff, and O. Langer, “Recurrent stillbirth: significance and characteristics,” Journal of Reproductive Medicine, vol. 38, no. 11, pp. 883–886, 1993.
[48]
S. Heinonen and P. Kirkinen, “Pregnancy outcome after previous stillbirth resulting from causes other than maternal conditions and fetal abnormalities,” Birth, vol. 27, no. 1, pp. 33–37, 2000.
