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.