Understanding the complexities of unexplained stillbirth in sub-Saharan Africa; a mixed-methods study

Objective: To understand the complexities surrounding unexplained stillbirth for the development and implementation of culturally acceptable interventions to underpin care in Tanzania and Zambia. Design: Mixed-methods. Setting: Tertiary, secondary and primary care facilities in Mansa, Zambia and Mwanza, Tanzania. Sample: Quantitative; 1997 women giving birth at two tertiary care facilities (one in each country). Qualitative; 48 women and 19 partners from tertiary, secondary and primary care facilities. Methods: Case review using data from a 2000 consecutive case record target. Qualitative interviews with a purposive sample of women and partners, using a grounded theory approach. Results: A total of 261 stillbirths were recorded; Tanzania rate 16%, Zambia 10%, higher than previous country estimates of 2.24% and 2.09%, respectively. Women in both countries who reported a previous stillbirth were more likely to have stillbirth (RR (95% CI): 1.86 (1.23 – 2.81)). Cause of death was unexplained in 28% of cases. Qualitative findings indicated that not knowing what caused the baby to be stillborn prevented women from grieving. This was compounded by poor communication skills of health professionals who displayed little empathy and skill when counselling bereaved families. Conclusion: Stillbirth risk in both facilities was far higher than national data, with women reporting a previous stillbirth at higher risk. Women want to know the cause of stillbirth and exploration of appropriate investigations in this setting is required. Providing health professionals with support and ongoing training is key to improving the experiences of women and future care. Funding: National Institute for Health Research. Keywords: Stillbirth, autopsy, communication, grief, sub-Saharan Africa, mixed-methods