This study included 1,998 neonates born to 1,926 mothers who consented to participate in the study. Most variables were obtained from all participants; and complete data were available for 1,989 births (99.5%).

Most mothers (63.4% n = 1222) were aged between 20 and 30 years, with only 2.6% (n = 51) of mothers aged over 40. The lower three tiers of household income were evenly distributed, around 30% of mothers in each tier with 11.1% (n = 215) in the upper two tiers of household income. The largest proportion of mothers reported living in a house (47.1% n = 907) with 30.2% (n = 581) living in an apartment, in this area an apartment would be the preferred choice, and 23% (n = 437) living in a shack. Over half of mothers had at least secondary school level education (61.7% n = 1,188), with 22.8% (n = 440) reporting to have no formal education and 15.5% (n = 298) educated to primary school level. The employment distribution was relatively even with 44.7% (n = 860) employed and 55.3% (n = 1066) unemployed. There was diversity among household access to water; water vendors supplied 33% (n = 636), 29.3% (n = 565) had access to a private well, 19% (n = 366) accessed water via a municipal network, e.g., home has water via a networked tap, this is the preferred option, 13% (n = 250) via communal taps and 5.7% (n = 109) via private boreholes. Most mothers had access to a sit/squat toilet with flush within the house (68.4% n = 1317), and 31.4% (n = 604) had access to a pit latrine (Supplementary table 1, supplementary file P12-14).

Most mothers had previously been pregnant 76.6% (n = 1476) and of the total cohort, 15.1% (n = 290) had previously experienced a stillbirth. Grand-multiparty is defined in this setting as having five or more children, 36.2% (n = 698) mothers were considered to have grandmultiparity. Most mothers reported having a healthy weight (89% n = 1715), 73.9% (n = 1424) reported taking some medication, antibiotic use was reported in 7.8% (n = 150) mothers and 28.1% (n = 542) reported taking antimalarial medication. Throughout pregnancy few mothers reported taking vitamins 8.1% (n = 150), with 40.4% (n = 779) taking folic acid/iron/platelets supplements and 55.1% (n=1062) reported taking pain relief. More than half (53.8% n = 1036) reported a health condition, 29.6% (n = 571) reported having malaria and 9.8% (n = 188) reported hypertension (Supplementary table 1, supplementary file P12-14).

Over half lived within 10 kilometres (km) of the hospital (58.4% n = 1125), as the distance increased the percentage of mothers decreased, yet some (0.8% n = 16) mothers travelled over 100 km to be admitted to the MMSH (Supplementary table 1, supplementary file P12-14).

Most mothers had at least one ultrasound during pregnancy (73.7% n = 1420) and 93.9% (n = 1808) noticed regular fetal movement in the prior 24 h to delivery. Multiple pregnancies made up 3.6% (n = 69) of the cohort. The most frequently observed mode of delivery was spontaneous vaginal delivery (SVD) (82.4% n = 1646), 15.5% (n = 309) were caesarean-sections, 2.1% (n = 42) deliveries were reported as vaginal breech. The most common presentation was cephalic; 88.4% (n = 1767), 9.3% (n = 185) breech presentation, 1.2% (n = 23) were compound presentation, 0.7% (n = 13) face presentation and 0.5% (n = 10) shoulder presentation. Signs of trauma were identified in 5% (n = 100) of neonates and 3.6% (n = 69) were part of a multiple birth (Supplementary table 1, supplementary file P12-14).

Of the 1998 births, 1789 were livebirths and 209 were stillbirths. Of the stillborn babies 100 had signs of maceration and 109 had no signs. The stillbirth rate within this cohort was 105/1000 births.

Bivariable models found associations between increased maternal age and stillbirth (Table 1). The mulitvariable models found that the association remained only within age categories 25–30 years (OR: 1.65, 95% CI: 1.07 to 2.55, p = 0.024) and 31–35 years (OR: 1.76, 95% CI: 1.04 to 3.00, p = 0.037) after adjusting for demographics, living environment and health and medical history (Table 2). After adjusting for pregnancy history, no evidence of an association was found between maternal age and stillbirth (Table 2). Bivariable models found that mothers educated up to primary school level had higher odds of stillbirth compared to those who had secondary school or above level of education; (OR 3.40, 95% CI: 2.52 to 4.59, p < 0.001) (Table 1), this finding remained after adjusting for all sociodemographic and health features (Table 2). No evidence of an association was found between stillbirth and household monthly income or employment status (Table 1). The pseudo r2 for the multivariable model including demographic features was 0.0562 (Supplementary table 2, supplementary file P15).

Table 1 Bivariable associations between sociodemographic, living environment, maternal health and medical history and pregnancy history variables and stillbirth
Table 2 Multivariable associations between sociodemographic, living environment, maternal health and medical history and pregnancy history variables and stillbirth

In the bivariable model, a greater distance to travel from home to the hospital was associated with higher odds of stillbirth (Table 1); this association remained after adjusting for sociodemographic and health features (Table 2). Distances were compared to a reference category of < 10 kms (10-30 km: OR: 1.52 95% CI: 1.08 to 2.12 p = 0.015; 31-50 km: OR: 3.64 95% CI: 1.93 to 6.85 p < 0.001; 51-100 km: OR: 3.39 95% CI: 1.25 to 9.21 p = 0.017 and > 100 km: OR: 4.44 95% CI: 1.31 to 15.05 p = 0.017). Living in a shack compared to an apartment or a house was associated with higher odds of stillbirth (OR: 2.59 95% CI: 1.92 to 3.49 p < 0.001) (Table 1). After adjusting for all sociodemographic and health features in the multivariable model this risk remained (Table 2).

Compared to a toilet with a flush, a pit latrine as the household toilet facilities was associated with higher odds of stillbirth (OR: 2.94 95% CI: 2.20 to 3.94 p < 0.001) (Table 1), this association remained after adjusting for all sociodemographic and health features in the multivariable model (Table 2). If the primary source of water was not a municipal network the odds of stillbirth were higher (OR: 1.90 95% CI: 1.22 to 2.96 p = 0.004) in the bivariable analysis. However, this association did not remain after adjusting for sociodemographic and health features. The pseudo-r2 for the multivariable model including demographic and living environment features was 0.0992, representing an absolute increase from the initial model of 0.043 and a relative increase of 76.5% (Supplementary table 2, supplementary file P15).

Bivariable models found the following factors to be associated with higher odds of stillbirth: mother’s perceived nutritional status as underweight (OR: 1.97 95% CI: 1.19 to 3.28 p = 0.009) and hypertension (OR: 1.88 95% CI: 1.26 to 2.82 p = 0.002) (Table 1). When adjusting for all sociodemographic and health features hypertension remained associated with higher odds of stillbirth (OR: 1.95 95% CI: 1.23 to 3.10 p = 0.005) (Table 2). Having fever or infection was associated with stillbirth, only once sociodemographic and health features had been adjusted for (OR: 2.53 95% CI: 1.12 to 5.70 p = 0.025) (Table 2). No evidence of an association was found between stillbirth and maternal use of antibiotics, anti-inflammatories, traditional medicine, antiretroviral therapy, or vitamins, neither was being overweight (Table 2). The pseudo-r2 for the multivariable model include demographic and living environment features was 0.1223 representing an absolute increase from the initial model of 0.0231 and a relative increase of 23.3% (Supplementary table 2, supplementary file P15).

In both the bivariable and multivariable models, a previous stillbirth was associated with higher odds of a stillbirth, after adjusting for all sociodemographic and health features the odds of having a stillbirth were over double that of a first-time mother (OR: 2.37, 95% CI: 1.64 to 3.42, p = <0.001) (Tables 1 and 2). The pseudo-r2 for the multivariable model include demographic and living environment features was 0.1394 representing an absolute increase from the initial model of 0.0171 and a relative increase of 14% (Supplementary table 2, supplementary file P15).

The bivariable analysis conducted on pregnancy and birth related factors are shown in Table 3. Compared to cephalic presentation shoulder presentation, compound presentation and breech presentation were all associated with higher odds of stillbirth (Shoulder: OR: 17.17, 95% CI: 4.79 to 61.54, p < 0.001; Compound: OR: 8.80, 95% CI: 3.79 to 20.43, p < 0.001; Breech: OR: 4.12, 95% CI: 2.85 to 5.96, p < 0.001). Birthing complications were associated with increased odds of stillbirth (OR: 5.98, 95% CI: 4.43 to 8.07, p < 0.001).

Table 3 Bivariable analysis; associations with pregnancy and birth related factors and stillbirth

Duration of labour which was 18 h or greater or reported unknown in duration were both associated with increased odds of stillbirth (≥ 18 h: OR: 2.92, 95% CI: 2.10 to 4.07, p < 0.001; unknown: OR: 3.42, 95% CI: 1.59 to 7.36, p = 0.002). Prolonged or obstructed labour was associated with increased stillbirth odds (OR: 3.34, 95% CI: 1.96 to 5.69, p < 0.001). Prolonged labour was adjusted for parity and remained statistically significantly associated with increased odds (OR: 1.61, 95% CI: 1.18 to 2.20, p = 0.003). Antepartum haemorrhage was associated with increased odds of stillbirth (OR: 6.66, 95% CI: 4.59 to 9.68, p < 0.001) (Table 3).

Compared to spontaneous vaginal delivery, vaginal breech delivery and emergency caesarean section were both associated with increased odds of stillbirth (VBD: OR: 4.61, 95% CI: 2.34 to 9.05, p < 0.001; EmC: OR: 2.89, 95% CI: 2.02 to 4.15, p < 0.001).

A non-linear association between gestational age and stillbirth was identified, with the odds of stillbirth decreasing as gestational age increased from 26 to 37 weeks, stable between 37 and 42 weeks and increasing again thereafter, with greater uncertainty at the extremes of our gestational ages (p-value for joint test of linear and quadratic term < 0.001) (Fig. 1). Similarly with birthweight and stillbirth a non-linear association was found, with the odds of stillbirth decreasing as birthweight increased from 0.5 kg to 3.0 kg, stable between 3.0 kg and 3.5 kg and increasing again thereafter (Supplementary Fig. 1, supplementary file P16).

Fig. 1
figure 1

Association between gestational age and stillbirth

Most associations were consistent with the binary stillbirth analysis (Supplementary table 3, supplementary file P17-19). However, there were some differences in statistically significant associations once divided into stillbirth classifications. The use of traditional medicine in the three months prior to birth was associated with a higher risk of non-macerated stillbirth (RR: 1.64, 95% CI: 1.01 to 2.67, p = 0.047), in the binary stillbirth analysis the use of traditional medicines and stillbirth were not statistically significantly associated. In the multinomial stillbirth analysis, being underweight was associated with a higher risk of non-macerated stillbirth only (RR: 2.73, 95% CI: 1.50 to 4.98, p = 0.001). The use of folic acid or iron supplements was associated with a lower risk of non-macerated stillbirth (RR: 0.64, 95% CI 0.42 to 0.97, p = 0.033). Across both stillbirth classifications malaria was no longer statistically significant. Hypertension was only associated with a higher risk of macerated stillbirths (RR: 2.20, 95% CI 1.29 to 3.76, p = 0.004). Having at least one ultrasound during pregnancy was associated with a lower risk of non-macerated stillbirth (RR: 0.66, 95% CI: 0.44 to 1.00, p = 0.049) whereas in the binary stillbirth analysis no association was found. The binary stillbirth analysis found that prolonged or obstructed labour was associated with a higher risk of stillbirth, yet within the multinomial stillbirth analysis the association was only statistically significant within non-macerated stillbirth (RR: 4.65, 95% CI: 2.49 to 8.65, p < 0.001). Compound presentation was found to be associated with non-macerated stillbirth (RR: 18.15, 95% CI: 7.47 to 44.05, p < 0.001). Breech presentation is more strongly associated with non-macerated stillbirth (macerated: RR: 2.24, 95% CI: 1.26 to 4.00, p = 0.006; non-macerated: RR: 6.55, 95% CI: 4.16 to 10.31, p < 0.001), shoulder and face presentation remain similar across both classifications. Being a mother aged over 25 years was statistically associated with a higher risk of macerated stillbirth, yet a higher risk of non-macerated stillbirth was only present within the age groups 36 years and over. Similarly for distance travelled to the hospital a higher risk of macerated stillbirth was associated with distances travelled in categories 31-50 km, 51-100 km and > 100 km and higher risk of non-macerated stillbirth were only found in distance categories 10-30 km and 31-50 km (Fig. 2a-c and Supplementary table 3, supplementary file P17-19).

Fig. 2
figure 2figure 2

a, b, c (top to bottom): Forest Plots showing associations with a.) sociodemographic, living environment, maternal health and medical history and pregnancy history, pregnancy and birth related, b.) distance from home to hospital, c.) presentation of baby during delivery and stillbirth overall, macerated stillbirth and non-macerated stillbirth

*Includes platelet and haemoglobin supplements

Further work was carried out exploring the association between birthweight and type of stillbirth outcome (macerated or non-macerated), with these findings suggesting that low birthweight < 2.3 kg was associated with a higher probability of a macerated stillbirth and higher birthweight > 3.0 kg was associated with a higher probability of non-macerated stillbirth (Supplementary Fig. 2, supplementary file P20). Similarly, low gestational age < 36 weeks was associated with a higher probability of macerated stillbirth and > 38 weeks gestational age was associated with a higher probability of non-macerated stillbirth (Supplementary Fig. 3, supplementary file P21).

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