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International Journal of Gynaecology... Mar 2022The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 has had dramatic effects on the pregnant population worldwide,...
BACKGROUND
The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 has had dramatic effects on the pregnant population worldwide, increasing the risk of adverse perinatal outcomes.
OBJECTIVE
To assess the incidence of antepartum stillbirth (aSB) during the COVID-19 pandemic in Austria.
METHODS
We collected epidemiological data from the Austrian Birth Registry and compared the rate of aSB (i.e., fetal death at or after 24 gestational weeks) during the pandemic period (March-December 2020) and in the respective pre-pandemic months (2015-2019).
RESULTS
In total, 65 660 pregnancies were included, of which 171 resulted in aSB at 33.7 ± 4.8 gestational weeks. During the pandemic, the aSB rate increased from 2.49‰ to 2.60‰ (P = 0.601), in contrast to the significant decline in preterm deliveries at or before 37 gestational weeks from 0.61‰ to 0.56‰ (relative risk [RR] 0.93; 95% confidence interval [CI] 0.91-0.96; P < 0.001). During the first lockdown, the aSB rate significantly increased from 2.38‰ to 3.52‰ (P = 0.021), yielding an adjusted odds ratio of 1.57 (95% CI 1.08-2.27; P = 0.018). The event of aSB during the COVID-19 pandemic was strongly related with increased fetal weight and maternal obesity.
CONCLUSION
In Austria, there has been an overall increase in the incidence of aSB during the pandemic with a significant peak during the first lockdown.
Topics: Austria; COVID-19; Communicable Disease Control; Female; Humans; Infant, Newborn; Pandemics; Pregnancy; Pregnancy Outcome; Premature Birth; SARS-CoV-2; Stillbirth
PubMed: 34669186
DOI: 10.1002/ijgo.13989 -
American Journal of Obstetrics and... Sep 2022The COVID-19 pandemic has been associated with a worsening of perinatal outcomes in many regions around the world. Melbourne, Australia, had one of the longest and most...
BACKGROUND
The COVID-19 pandemic has been associated with a worsening of perinatal outcomes in many regions around the world. Melbourne, Australia, had one of the longest and most stringent lockdowns worldwide in 2020 while recording only rare instances of COVID-19 infection in pregnant women.
OBJECTIVE
This study aimed to compare the stillbirth and preterm birth rates in women who were exposed or unexposed to lockdown restrictions during pregnancy.
STUDY DESIGN
This was a retrospective, multicenter cohort study of perinatal outcomes in Melbourne before and during the COVID-19 lockdown. The lockdown period was defined as the period from March 23, 2020 to March 14, 2021. Routinely-collected maternity data on singleton pregnancies ≥24 weeks gestation without congenital anomalies were obtained from all the 12 public hospitals in Melbourne. We defined the lockdown-exposed cohort as those women for whom weeks 20 to 40 of gestation occurred during the lockdown and the unexposed control group as women from the corresponding calendar periods 12 and 24 months before. The main outcome measures were stillbirth, preterm birth, fetal growth restriction (birthweight < third centile), and iatrogenic preterm birth for fetal compromise. We performed multivariable logistic regression analysis to compare the odds of stillbirth, preterm birth, fetal growth restriction, and iatrogenic preterm birth for fetal compromise, adjusting for multiple covariates.
RESULTS
There were 24,817 births in the exposed group and 50,017 births in the control group. There was a significantly higher risk of preterm stillbirth in the exposed group than the control group (0.26% vs 0.18%; adjusted odds ratio, 1.49; 95% confidence interval, 1.08-2.05; P=.015). There was also a significant reduction in the preterm birth of live infants <37 weeks (5.68% vs 6.07%; adjusted odds ratio, 0.93; 95% confidence interval, 0.87-0.99; P=.02), which was largely mediated by a significant reduction in iatrogenic preterm birth (3.01% vs 3.27%; adjusted odds ratio, 0.91; 95% confidence interval, 0.83-0.99; P=.03), including iatrogenic preterm birth for fetal compromise (1.25% vs 1.51%; adjusted odds ratio, 0.82; 95% confidence interval, 0.71-0.93; P=.003). There were also significant reductions in special care nursery admissions during lockdown (11.53% vs 12.51%; adjusted odds ratio, 0.90; 95% confidence interval, 0.86-0.95; P<.0001). There was a trend to fewer spontaneous preterm births <37 weeks in the exposed group of a similar magnitude to that reported in other countries (2.69% vs 2.82%; adjusted odds ratio, 0.95; 95% confidence interval, 0.87-1.05; P=.32).
CONCLUSION
Lockdown restrictions in Melbourne, Australia were associated with a significant reduction in iatrogenic preterm birth for fetal compromise and a significant increase in preterm stillbirths. This raises concerns that pandemic conditions in 2020 may have led to a failure to identify and appropriately care for pregnant women at an increased risk of antepartum stillbirth. Further research is required to understand the relationship between these 2 findings and to inform our ongoing responses to the pandemic.
Topics: COVID-19; Cohort Studies; Communicable Disease Control; Female; Fetal Growth Retardation; Humans; Iatrogenic Disease; Infant; Infant, Newborn; Pandemics; Pregnancy; Premature Birth; Retrospective Studies; Stillbirth
PubMed: 35452655
DOI: 10.1016/j.ajog.2022.04.022 -
PloS One 2022To assess the risk of singleton intrauterine fetal death (IUFD) in women by the demographic setting of the online Fetal Medicine Foundation (FMF) Stillbirth Risk...
OBJECTIVE
To assess the risk of singleton intrauterine fetal death (IUFD) in women by the demographic setting of the online Fetal Medicine Foundation (FMF) Stillbirth Risk Calculator.
METHODS
Retrospective single-centre case-control study involving 144 women having suffered IUFD and 247 women after delivery of a live-born singleton. Nonparametric receiver operating characteristics (ROC) analyses were performed to predict the prognostic power of the FMF Stillbirth risk score and to generate a cut-off value to discriminate best between the event of IUFD versus live birth.
RESULTS
Women in the IUFD cohort born a significantly higher overall risk with a median FMF risk score of 0.45% (IQR 0.23-0.99) compared to controls [0.23% (IQR 0.21-0.29); p<0.001]. Demographic factors contributing to an increased risk of IUFD in our cohort were maternal obesity (p = 0.002), smoking (p<0.001), chronic hypertension (p = 0.015), antiphospholipid syndrome (p = 0.017), type 2 diabetes (p<0.001), and insulin requirement (p<0.001). ROC analyses showed an area under the curve (AUC) of 0.72 (95% CI 0.67-0.78; p<0.001) for predicting overall IUFD and an AUC of 0.72 (95% CI 0.64-0.80; p<0.001), respectively, for predicting IUFD excluding congenital malformations. The FMF risk score at a cut-off of 0.34% (OR 6.22; 95% CI 3.91-9.89; p<0.001) yielded an 82% specificity and 58% sensitivity in predicting IUFD with a positive and negative predictive value of 0.94% and 99.84%, respectively.
CONCLUSION
The FMF Stillbirth Risk Calculator based upon maternal demographic and obstetric characteristics only may help identify women at low risk of antepartum stillbirth.
Topics: Perinatology
PubMed: 35051188
DOI: 10.1371/journal.pone.0260964 -
The Cochrane Database of Systematic... Nov 2014Domestic violence during pregnancy is a major public health concern. This preventable risk factor threatens both the mother and baby. Routine perinatal care visits offer... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Domestic violence during pregnancy is a major public health concern. This preventable risk factor threatens both the mother and baby. Routine perinatal care visits offer opportunities for healthcare professionals to screen and refer abused women for effective interventions. It is, however, not clear which interventions best serve mothers during pregnancy and postpartum to ensure their safety.
OBJECTIVES
To examine the effectiveness and safety of interventions in preventing or reducing domestic violence against pregnant women.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014), scanned bibliographies of published studies and corresponded with investigators.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) including cluster-randomised trials, and quasi-randomised controlled trials (e.g. where there was alternate allocation) investigating the effect of interventions in preventing or reducing domestic violence during pregnancy.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.
MAIN RESULTS
We included 10 trials with a total of 3417 women randomised. Seven of these trials, recruiting 2629 women, contributed data to the review. However, results for all outcomes were based on single studies. There was limited evidence for the primary outcomes of reduction of episodes of violence (physical, sexual, and/or psychological) and prevention of violence during and up to one year after pregnancy (as defined by the authors of trials). In one study, women who received the intervention reported fewer episodes of partner violence during pregnancy and in the postpartum period (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.43 to 0.88, 306 women, moderate quality). Groups did not differ for Conflict Tactics Score - the mean partner abuse scores in the first three months postpartum (mean difference (MD) 4.20 higher, 95% CI -10.74 to 19.14, one study, 46 women, very low quality). The Current Abuse Score for partner abuse in the first three months was also similar between groups (MD -0.12 lower, 95% CI -0.31 lower to 0.07 higher, one study, 191 women, very low quality). Evidence for the outcomes episodes of partner abuse during pregnancy or episodes during the first three months postpartum was not significant (respectively, RR 0.50, 95% CI 0.25 to 1.02, one study with 220 women, very low quality; and RR 0.60, 95% CI 0.35 to 1.04, one study, 271 women, very low quality). Finally, the risk for low birthweight (< 2500 g) did not differ between groups (RR 0.74, 95 % CI 0.41 to 1.32, 306 infants, low quality).There were few statistically significant differences between intervention and control groups for depression during pregnancy and the postnatal period. Only one study reported findings for neonatal outcomes such as preterm delivery and birthweight, and there were no clinically significant differences between groups. None of the studies reported results for other secondary outcomes: Apgar score less than seven at one minute and five minutes, stillbirth, neonatal death, miscarriage, maternal mortality, antepartum haemorrhage, and placental abruption.
AUTHORS' CONCLUSIONS
There is insufficient evidence to assess the effectiveness of interventions for domestic violence on pregnancy outcomes. There is a need for high-quality, RCTs with adequate statistical power to determine whether intervention programs prevent or reduce domestic violence episodes during pregnancy, or have any effect on maternal and neonatal mortality and morbidity outcomes.
Topics: Domestic Violence; Female; Humans; Pregnancy; Pregnancy Outcome; Pregnant Women; Randomized Controlled Trials as Topic; Safety; Sex Offenses
PubMed: 25390767
DOI: 10.1002/14651858.CD009414.pub3 -
BJOG : An International Journal of... Jan 2024Sub-Saharan African (SSA) countries have high stillbirth rates compared with high-income countries, yet research on risk factors for stillbirth in SSA remain scant. (Review)
Review
BACKGROUND
Sub-Saharan African (SSA) countries have high stillbirth rates compared with high-income countries, yet research on risk factors for stillbirth in SSA remain scant.
OBJECTIVES
To identify the modifiable risk factors of stillbirths in SSA and investigate their strength of association using a systematic review.
SEARCH STRATEGY
CINAHL Plus, EMBASE, Global Health and MEDLINE databases were searched for literature.
SELECTION CRITERIA
Observational population- and facility-level studies exploring stillbirth risk factors, published in 2013-2019 were included.
DATA COLLECTION AND ANALYSIS
A narrative synthesis of data was undertaken and the potential risk factors were classified into subgroups.
MAIN RESULTS
Thirty-seven studies were included, encompassing 20 264 stillbirths. The risk factors were categorised as: maternal antepartum factors (0-4 antenatal care visits, multiple gestations, hypertension, birth interval of >3 years, history of perinatal death); socio-economic factors (maternal lower wealth index and basic education, advanced maternal age, grand multiparity of ≥5); intrapartum factors (direct obstetric complication); fetal factors (low birthweight and gestational age of <37 weeks) and health systems factors (poor quality of antenatal care, emergency referrals, ill-equipped facility). The proportion of unexplained stillbirths remained very high. No association was found between stillbirths and body mass index, diabetes, distance from the facility or HIV.
CONCLUSIONS
The overall quality of evidence was low, as many studies were facility based and did not adjust for confounding factors. This review identified preventable risk factors for stillbirth. Focused programmatic strategies to improve antenatal care, emergency obstetric care, maternal perinatal education, referral and outreach systems, and birth attendant training should be developed. More population-based, high-quality research is needed.
Topics: Pregnancy; Female; Humans; Infant; Stillbirth; Prenatal Care; Perinatal Death; Pregnancy Complications; Africa South of the Sahara
PubMed: 37272228
DOI: 10.1111/1471-0528.17562 -
PloS One 2016The burden of maternal complications during antepartum and intrapartum periods is high and care seeking from a trained provider is low, particularly in low middle income...
BACKGROUND
The burden of maternal complications during antepartum and intrapartum periods is high and care seeking from a trained provider is low, particularly in low middle income countries of sub-Saharan Africa and South Asia. Identification of barriers to access to trained care and development of strategies to address them will contribute to improvements in maternal health. Using data from a community-based cohort of pregnant women, this study identified the prevalence of antepartum and intrapartum complications and determinants of care-seeking for these complications in rural Bangladesh.
METHODS
The study was conducted in 24,274 pregnant women between June 2011 and December 2013 in rural Sylhet district of Bangladesh. Women were interviewed during pregnancy to collect data on demographic and socioeconomic characteristics; prior miscarriages, stillbirths, live births, and neonatal deaths; as well as data on their ability to make decision to go to health center alone. They were interviewed within the first 7 days of child birth to collect data on self-reported antepartum and intrapartum complications and care seeking for those complications. Bivariate analysis was conducted to explore association between predisposing (socio-demographic), enabling (economic), perceived need, and service related factors with care-seeking for self-reported antepartum and intrapartum complications. Multivariable multinomial logistic regression was performed to examine the association of selected factors with care-seeking for self-reported antepartum and intrapartum complications adjusting for co-variates.
RESULTS
Self-reported antepartum and intrapartum complications among women were 14.8% and 20.9% respectively. Among women with any antepartum complication, 58.9% sought care and of these 46.5% received care from a trained provider. Of the women with intrapartum complications, 61.4% sought care and of them 46.5% did so from a trained provider. Care-seeking for both antepartum and intrapartum complications from a trained provider was significantly higher for women with higher household wealth status, higher literacy level of both women and their husbands, and for those living close to a health facility (<10 km). Women's decision making ability to go to health centre alone was associated with untrained care only for antepartum complications, but was associated with both trained and untrained care for intrapartum complications.
CONCLUSIONS
Nearly 40.0% of the women who experienced either an antepartum or intrapartum complications did not seek care from any provider and 11.5% -14.9% received care from untrained providers, primarily because of economic and geographic barriers to access. Development and evaluation of context specific, cost-effective, and sustainable strategies that will address these barriers to access to care for the maternal complications will enhance care seeking from trained health care providers and improve maternal health.
Topics: Adolescent; Adult; Bangladesh; Delivery of Health Care; Female; Humans; Patient Acceptance of Health Care; Pregnancy; Pregnancy Complications; Rural Population; Socioeconomic Factors
PubMed: 27997537
DOI: 10.1371/journal.pone.0167814 -
BMC Pregnancy and Childbirth Jun 2022With the development of assisted reproductive technology, the twinning rate in China has been increasing. However, little is known about twinning from 2014 onwards. In... (Observational Study)
Observational Study
BACKGROUND
With the development of assisted reproductive technology, the twinning rate in China has been increasing. However, little is known about twinning from 2014 onwards. In addition, previous studies analysing optimal gestational times have rarely considered maternal health conditions. Therefore, whether maternal health conditions affect the optimal gestational time remains unclear.
METHODS
Data of women delivered between January 2012 and December 2020 were collected through China's National Maternal Near Miss Surveillance System. Interrupted time series analysis was used to determine the rates of twinning, stillbirth, smaller than gestational age (SGA), and low Apgar scores (< 4) among twins in China. To estimate the risk of each adverse perinatal outcome for separate gestational weeks, a multivariate generalised linear model was used. Infants born at 37 weeks of gestational age or foetuses staying in utero were used as reference separately. The analyses were adjusted for the sampling distribution of the population and the cluster effect at the hospital and individual levels were considered.
RESULTS
There were 442,268 infants enrolled in this study, and the adjusted rates for twinning, stillbirth, SGA, and low Apgar scores were 3.10%, 1.75%, 7.70%, and 0.79%, respectively. From 2012 to 2020, the twinning rate showed an increasing trend. Adverse perinatal outcomes, including stillbirth, SGA, and low Apgar scores showed a decreasing trend. A gestational age between 34 and 36 weeks decreased most for rate of stillbirth (average changing rate -9.72%, 95% confidence interval [CI] -11.41% to -8.00%); and a gestational age of between 37 and 38 weeks decreased most for rates of SGA (average changing rate -4.64%, 95% CI -5.42% to -3.85%) and low Apgar scores (average changing rate -17.61%, 95% CI -21.73% to -13.26%). No significant difference in changes in twinning rate or changes of each perinatal outcome was observed during periods of different fertility policies. Infants born at 37 weeks of gestation had a decreased risk of stillbirth, SGA, and low Apgar scores. Maternal antepartum or medical complications increased the risk of SGA and low Apgar scores in different gestational weeks.
CONCLUSION
China's twinning rate showed an increasing trend, while adverse perinatal outcomes decreased from 2012 to 2020. Fertility policy changes have had little effect on the twinning rate or the rate of adverse perinatal outcomes such as stillbirth, SGA, or low Apgar scores. The optimal gestational age for twins was 37 weeks. Women pregnant with twins and with antepartum or medical complications should be cautious due to an increased risk of SGA and low Apgar scores.
Topics: Female; Gestational Age; Humans; Infant; Infant, Newborn; Infant, Small for Gestational Age; Parturition; Pregnancy; Pregnancy, Twin; Stillbirth
PubMed: 35659606
DOI: 10.1186/s12884-022-04766-0 -
Cureus Sep 2023Background One of the leading causes contributing to morbidity and mortality globally is attributed to eclampsia. Hence, it is vital to comprehensively review each...
Background One of the leading causes contributing to morbidity and mortality globally is attributed to eclampsia. Hence, it is vital to comprehensively review each female having eclampsia and to evaluate the factors that govern the outcomes in females with eclampsia. Aim To decode the fetal and maternal outcomes in subjects having eclampsia and to evaluate various factors that govern the outcomes. Methods This retrospective cohort and epidemiological study commenced at the Department of Obstetrics and Gynaecology, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, in January 2016 till April 2017, and included females that either developed eclampsia in hospital stay duration or presented with pre-existing eclampsia. In included females, various fetal and maternal parameters were assessed along with the outcome of pregnancy. The institutional data records and the database were also used to determine the prevalence and incidence of eclampsia. Baseline maternal parameters were recorded from the already-existing institute data. These included the gestational age (in years), socioeconomic status, educational attainment, parity, gravidity, and the number of weeks of gestation present at the time of delivery. Antenatal care data assessed were blood pressure recordings, any proteinuria documented in the data, and the number of antenatal visits by the subjects. Statistical analysis was performed to assess both parameters. Results In the current investigation, there were 0.34% eclampsia cases among females visiting the institution for deliveries. Incidences of stillbirth were seen in 19.04% and 8% of study participants, respectively. We found 9.52% (n=4) of female infants to have perished from eclampsia. Preterm births, a delayed start to the treatment, and insufficient care were all linked to poor foetal and mother outcomes. The longer the period between the beginning of a fit and delivery, the greater the likelihood of unfavourable results. Seizure onset before or after birth, parity, or subject age had no impact on mother or foetal health. The p-value for statistical significance was kept at 0.05. Conclusion Most of the research participant women, had intrapartum eclampsia, postpartum eclampsia, and antepartum eclampsia, based on the time of the convulsions in relation to the labor. It was highlighted that there was no conclusive evidence linking the date of the fit's beginning to unfavourable results or an elevated risk of complications. Neonatal mortality and stillbirth were observed with vaginal delivery in eclampsia cases. Outcomes in eclampsia can be improved by early treatment initiation, timely and appropriate referral, early disease recognition, and appropriate antenatal care.
PubMed: 37900531
DOI: 10.7759/cureus.45971 -
BMC Pregnancy and Childbirth Sep 2021Ethiopia is a Sub-Saharan country that has made significant improvements in maternal mortality and under-five mortality over the past 15 years. However, the nation...
BACKGROUND
Ethiopia is a Sub-Saharan country that has made significant improvements in maternal mortality and under-five mortality over the past 15 years. However, the nation continues to have one of the highest rates of perinatal mortality in the entire world with current estimates at 33 deaths per 1000 live births.
METHODS
This case-control study was conducted between October 2016 and May 2017 at Tikur Anbessa Hospital and Gandhi Memorial Hospital. All women who had a stillbirth or early neonatal death (i.e. death within 7 days) during this period willing to participate were included as cases. A systematic random sample of women delivering at the hospital were approached for recruitment as controls to generate a 2:1 ratio of controls to cases. Data on risk factors were retrieved from medical records including delivery records, and treatment charts. Statistical differences in background and social characteristics of cases and controls were determined by t-test and chi-squared (or fisher's exact test) for quantitative and categorical variables respectively. Binary logistic regression analysis was completed to determine any associations between risk factors and stillbirth/early neonatal death.
RESULTS
During the study period, 366 women delivering at the hospitals were enrolled as cases and 711 women delivering at the hospitals were enrolled as controls. Records from both hospitals indicated that the estimated stillbirth and neonatal mortality rates were 30.7 per 1000. Neonatal causes (43.4%) were the most common, followed by antepartum (32.5%) and intrapartum (24.5%). Risk factors for stillbirths and early neonatal death were low maternal education (aOR 1.747, 95%CI 1.098-2.780), previous stillbirth (aOR 9.447, 95%CI 6.245-14.289), previous preterm birth (aOR 3.620, 95%CI 2.363-5.546), and previous child with congenital abnormality (aOR 2.190, 95% 1.228-3.905), and antepartum hemorrhage during pregnancy (aOR 3.273, 95% 1.523-7.031).
CONCLUSION
Antepartum hemorrhaging is the only risk factor in our study amenable for direct intervention. Efforts should be maximized to improve patient education and antenatal and obstetric services. Moreover, the most significant cause of mortality was asphyxia-related causes. It is imperative that obstetric capacity in rehabilitation services are strengthened and for further studies to investigate the high burden of asphyxia at these tertiary hospitals to better tailor interventions.
Topics: Adult; Case-Control Studies; Ethiopia; Female; Humans; Infant, Newborn; Male; Perinatal Death; Perinatal Mortality; Pregnancy; Risk Factors; Stillbirth; Tertiary Care Centers; Young Adult
PubMed: 34548064
DOI: 10.1186/s12884-021-04025-8 -
PloS One 2017It is estimated that everyday 7000 women worldwide have their pregnancy end with a stillbirth, however, research and data collection on stillbirth remains underfunded....
It is estimated that everyday 7000 women worldwide have their pregnancy end with a stillbirth, however, research and data collection on stillbirth remains underfunded. This stillbirth case series audit investigates an apparent rise in stillbirths at a Sydney tertiary referral hospital in Australia. A retrospective case series of singleton stillbirths from 2005-2010 was conducted at Westmead Hospital. Stillbirth was defined as per the Perinatal Society of Australia and New Zealand classification as a death of a baby before or during birth, from the 20th week of pregnancy onwards, or a birth weight of 400 grams or more if gestational age is unknown. A total of 215 singleton stillbirths were identified in a cohort of 28 109, a rate of 7.6 per 1000 singleton births. There was a significant increase in annual stillbirth rate at our institution; the rate exceeded both Australian national and state singleton stillbirth rates. After pregnancy terminations over 20 weeks were excluded from the data, there was no statistical change in the stillbirth rate over time. Congenital anomalies (27%) and unexplained antepartum death (15%) remained as major causes; fetal growth restriction (17%) was also identified as an increasingly important cause, particularly in preterm gestations. Termination of pregnancy after 20 weeks was found to be the cause of rising stillbirth rate at our institution. Local and national data collection on stillbirth should be standardised and should include differentiation of termination of pregnancy as a separate entity so as to accurately assess stillbirth to target appropriate research and resource allocation.
Topics: Adult; Australia; Birth Weight; Cause of Death; Data Collection; Female; Gestational Age; Hospital Mortality; Hospitals, Urban; Humans; Infant, Newborn; Logistic Models; Maternal Age; Perinatal Care; Pregnancy; Retrospective Studies; Risk Factors; Stillbirth; Tertiary Care Centers; Young Adult
PubMed: 28192505
DOI: 10.1371/journal.pone.0171829