Main findings
Our study is the first to investigate the causes of stillbirth in the Solomon Islands. The incidence of stillbirth at the National Referral Hospital was 30.8 cases per 1,000 births. This is almost two-fold greater than the most recent WHO estimate for the Solomon Islands (17.6 per 1000 total births).7
Many stillbirths in LMICs may be prevented through improved antenatal care.3, 13 Whilst most mothers had at least one antenatal visit, we found significant gaps in the quality of care received. A third of our cohort were living outside of the main island and, again, one third were referred for care. This highlights the challenges of delivering high quality antenatal care in peripheral and remote settings. Recent global studies have shown that many cases of stillbirth considered secondary to fetal growth restriction or preterm birth, in particular, may be preventable through improved antenatal monitoring and interventions. 3, 13, 14 Early ultrasound assessment is vital for dating and diagnosis of potential fetal growth restriction 14, 15, however only 25% of mothers received an early ultrasound in our cohort. Of the 85% of stillbirths occurring antenatally, suspected growth restriction was common, with almost 60% were born at a low birthweight. Over 60% of stillbirths occurred at preterm gestations. Of these, 80% were over 28 weeks gestations and many of these could have been potentially preventable if there was early detection of the low birthweight. Whilst access to ultrasound examination is particularly challenging in this setting, our study has highlighted the potential to reduce stillbirths if services were expanded.
Routine antenatal testing for syphilis (a major cause of stillbirth globally. 2, 3, 16) is also recommended as part of antenatal care. A deficiency in testing of syphilis was evident in our cohort, with 53% (10 babies) of the 19 antenatal stillbirths associated with infection showing overt signs of congenital syphilis infection, however only one third of women were tested. Point of care syphilis testing is cost-effective and a potential resource in LMICs, particularly in rural and remote settings where laboratory services are not readily available. 16, 17 Once diagnosed, complete treatment and clearance of syphilis in the woman and partner can decrease the risk pf stillbirth. However, in the present study only seven women completed treatment and there was minimal data on partner testing, which may be attributed to multiple factors, including lack of penicillin and poor patient and partner understanding.
Education regarding family planning, prevention and danger signs of pregnancy, such as reduced fetal movements, and birth preparedness are also vital aspects of antenatal care. However, almost half of the women within our study did not have documentation regarding discussion of danger signs during antenatal care. Provided with this information these women may have presented earlier and some cases may have been prevented. The late terminations of pregnancy and high parity within our cohort also point to a significant unmet need for family planning.18 Abortion is illegal in the Solomon Islands, which highlights the complexity of this issue. This emphasizes the demand for improved patient and community education and access to reproductive services to reduce unwanted pregnancy. 13, 14
The largest proportion of stillbirths were unclassified (or cause unknown), which is in keeping with other studies in LMICs and largely due to lack of diagnostic tools and inadequate documentation.19, 20 We found 14% of stillbirths occurred during labour and almost half of these were due to an acute, preventable intrapartum event. Fetal heart rate monitoring was not documented in the majority of these stillbirths. Whilst this is challenging due to limitations in number of healthcare workers, this highlights the urgent need for improvement in training and provision of resources to enable safer intrapartum care. Additionally, our intrapartum stillbirth rate was lower than previous studies1-3, 21, with a recent study in Timor-Leste showing an intrapartum stillbirth rate of 33%.21 The significant number of missing case files may have led to an underrepresentation of intrapartum deaths. This is certainly plausible given the majority of intrapartum stillbirths had severe suboptimal care. This may be also be attributable to inaccurate classification of some stillbirths as antepartum in those where case files were available, as a quarter of cases in our study did not have adequate documentation of maceration. Overall, we found the incidence of stillbirth in the Solomon Islands to be higher than the average stillbirth rate for its two closest neighbours, Papua New Guinea and Fiji (rates of 15.9 and 11.9 per 1000 births, respectively).7, 21 This may be due to referral bias; however, the proportional causes of stillbirth are still likely to reflect the national rate.
Whilst there is much progress to be made, it is promising that some of the gaps highlighted by our study are being addressed in a recent updated Antenatal Care Package, launched by The Solomon Islands Ministry of Health and the World Health Organisation. This package incorporates focussed health worker education and resource provision, such as improved access to antenatal ultrasounds and point of care syphilis and haemoglobin testing. This initiative acknowledges the socioeconomic return of investing in stillbirths 2 and is a fundamental step in reducing the burden of perinatal death in the Solomon Islands.