Anaemia in pregnancy is an important reproductive health problem. According to NFHS-4 (NFHS) [1], in Rajasthan, anaemia (Hb<11gm%) was seen in 46.8% of pregnant women aged 15-49 year. It is associated with increased maternal and perinatal morbidity and mortality [2].

Stillbirth rate, an important indicator of the health status of a population, for India is 4 per 1000 birth and 6 per 1000 birth for Rajasthan [3]. Over 50% of the stillbirths occur during the antepartum period (International Classification of Diseases-ICD 10 code- P 95) [4]. 

Objective

The objective of this study was to evaluate maternal anaemia as a risk for antepartum stillbirth.

The observational study was done over a period of six months in the Obstetrics and Gynaecology Department of in a tertiary care centre. Women admitted in labour room with singleton pregnancy more than 28 weeks were selected. Forty antepartum stillbirths and eighty live births (one born before and one after each stillbirth) were included. Pregnancies with any medical disease or intrapartum stillbirth were excluded. Sample size calculated was based on the work of Ashish et al. [5]. Informed consent was taken from each patient included in the study. Data was analysed to evaluate anaemia as a risk factor for stillbirth.

Majority, i.e. 53.3% women were anaemic. Among women who had antepartum stillbirth 22.5% had moderate and12.5% had severe anaemia. The mean Hb of women with stillbirth was 9.83 mg/dl whereas that of those with live births was higher 10.76 mg/dl. The difference in haemoglobin of women with stillbirth and those with live birth was found to be statistically significant (p=0.039) (Table 1).

Table 1: Anaemia as a variable of risk of antepartum stillbirth

Chi-square = 8.904 with 3 degrees of freedom, p = 0.039 (S)

As compared to women without anaemia, women with anaemia were at higher risk of antepartum stillbirth. The odds ratio was higher in those with severe anaemia (odds ratio-13.67) than those with moderate (odds ratio-2.05) and mild anaemia (odds ratio-1.16).

There were ten foetuses that were growth restricted, of which only one, with mild anaemia was born live. The mean Hb of the growth restricted stillbirth foetuses was 8.3 mg/dl (Table 2).

Table 2: Anaemia and Stillbirth in Growth Restricted Foetus

Our study showed that anaemia was a major risk factor for stillbirth. The mean Hb was lower in women with stillbirths. Mothers with growth restricted foetus too had lower haemoglobin and higher stillbirth rate.

Akhter and Daisy [6] and Ibrahimou et al. [7] also observed that anaemia was a risk factor, found in 2.7% to 16.55 % stillbirth. In a similar study by Vaishali and Pradeep [8], 61.2% women with stillbirths had Hb <10gm%.

A study conducted in Ahmedabad, India also identified lack of antenatal care as a risk factor for stillbirth [9]. They reported that maternal anaemia was very prevalent among pregnant women of their setting and represented an important foetal insult that raised the risk of prematurity, SGA and stillbirth.

The prevalence of anaemia in pregnancy varies considerably because of differences in socioeconomic conditions, lifestyles and health-seeking behaviours across different cultures [10]. Kalaivani reported that women in the remote rural areas in India reach to the hospital only at a late decompensated stage [11]. This leads to increased perinatal morbidity and mortality.

Anaemia causes less oxygenation of the body organs including placenta which produce placental hypoxia leading to placental insufficiency and intra uterine growth restriction of foetus [8]. In severe anaemia, it may lead to abruption placentae or even foetal loss.

In women with mild and moderate anaemia, history of poor antenatal care is often observed. 

Improvement in antenatal care would help diagnose anaemia in early stages. Because the majority of the anaemic gravidae were in the low social class, provision of haematinics will go a long way towards reducing the high prevalence of anaemia in pregnancy [5]. This would thus decrease incidence of growth restriction and stillbirths and thus improve the foetal outcome.

1. International Institute for Population Sciences. “Key findings from National Family Health Survey.” National Family Health Survey-4, www.rchiips.org/NFHS/pdf/ NFHS4/India.pdf. Accessed 18 November 2019.

2. Bukar, M. et al. “Anaemia in pregnancy at booking in Gombe, north-eastern Nigeria.” Journal of Obstetrics and Gynaecology, vol. 28, no. 8, 2008, pp. 775–778.

3. Census of India. “Mortality indicators 2015.” Sample Registration System Report 2015. Government of India, 2015, www.censusindia.gov.in/vital_statistics/SRS_Report_2015/8.Chap%204-Mortality%20Indicators-2015. Accessed 20 October 2017.

4. World Health Organization. Making Every Baby Count: Audit and Review of Stillbirths and Neonatal Deaths. World Health Organization, 2016.

5. Ashish, K.C. et al. “Risk factors for antepartum stillbirth: a case-control study in Nepal.” BMC Pregnancy and Childbirth, vol. 15, no. 1, 2015, article 146.

6. Akhter, H. and K.P. Daisy. “Magnitude and risk factors of stillbirth in a tertiary hospital.” Dinajpur Medical College Journal, vol. 2, 2009, pp. 52–57.

7. Ibrahimou, B. et al. “Previous preterm birth and current maternal complications as a risk factor of subsequent stillbirth.” Advances in Epidemiology, vol. 2015, 2015.

8. Vaishali, N. Korde-Nayak and R. Gaikwad Pradeep. “Causes of stillbirth.” The Journal of Obstetrics and Gynaecology of India, vol. 58, no. 4, 2008, pp. 314–318.

9. Mavalankar, D.V. et al. “Levels and risk factors for perinatal mortality in Ahmedabad, India.” Bulletin of the World Health Organization, vol. 69, no. 4, 1991, pp. 435–442.

10. Al-Mehaisen, L. et al. “Maternal anaemia in rural Jordan: room for improvement.” Anaemia, vol. 2011, 2011.

11. Kalaivani, K. “Prevalence and consequences of anaemia in pregnancy.” Indian Journal of Medical Research, vol. 130, no. 5, 2009, pp. 627–633.