AMJ Vol 9 No 4 Desember 2022 Final.indd


Althea Medical Journal. 2022;9(4)

228     

 Risk Factor of Stillbirth among Pregnant Women at Dr. Hasan Sadikin 
General Hospital Bandung from 2017–2020

David Immanuel,1 Hadi Susiarno,2 Windi Nurdiawan2
¹Faculty of Medicine Universitas Padjadjaran, Indonesia, ²Department of Obstetrics and 

Gynecology Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital 
Bandung, Indonesia

Correspondence: David Immanuel, Faculty of Medicine Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, 
Jatinangor, Sumedang, Indonesia, Email: david18006@mail.unpad.ac.id

Introduction

Stillbirth is a pregnancy condition when the 
fetus dies at 20 weeks’ gestation or after.1 The 
World Health Organization (WHO) has different 
criteria in defining stillbirth, primarily from 
the gestational age and fetal weight aspects. 
For international comparison and reporting, 
WHO set 28 weeks of gestation as the cut-off 
and 1,000 grams as the weight. Classification 
of stillbirth is based on the gestational age (in 
weeks) when the diagnosis is established, for 
stillbirth that occurrs from 20 to 28 weeks of 
gestation is called  early stillbirth, and after 28 
weeks as  late stillbirth. Another classification 
relies on its occurrence between any time 
during labor/delivery period, with antepartum 
stillbirth that occurred before labor onset and 
intrapartum stillbirth that occurred during the 

labor process.2 
On average, 2.6 million stillbirth cases were 

reported worldwide in 2015 (varies from 2.4–
3.0 million), with 98% of cases reported being 
from low and middle-income countries and 
66% from developing countries. One of them 
is Indonesia which took the eighth position as 
a country with the highest number of stillbirth 
cases, along with other nations such as India, 
China, and Pakistan.3 In Indonesia, there were 
3,097 cases reported in West Java province 
from a total of 935,003 births and 129 cases 
in Bandung city from a total of 39,571 births, 
with the number of cases mentioned were 
accumulated from both male and female 
fetuses.4 

Several factors associated with stillbirth 
are classified based on the pathological 
origin, such as maternal, fetal, placental, 

Althea Medical Journal. 2022;9(4):228–233

Abstract

Background: Stillbirth is one of the most devastating pregnancy outcomes that affects approximately 
2.6 million pregnancies worldwide. Several factors have been identified to be associated with stillbirth, 
and grouped based on the pathophysiological aspects, such as maternal, placental, fetal, and unknown 
or unexplained factors. This study aimed to describe the prevalence, along with the baseline and risk 
factor characteristics of stillbirth among singleton pregnancies at Dr. Hasan Sadikin General Hospital 
Bandung. 
Methods: A descriptive, cross-sectional study design was conducted, including all stillbirth medical 
records from 2017 to 2020 obtained from the Department of Obstetrics and Gynecology, Dr. Hasan 
Sadikin General Hospital Bandung. Medical records with complete baseline data, 2nd–3rd trimester 
pregnancies, and singleton pregnancies were collected.
Results: The prevalence of stillbirth cases in this study was 2.2%. Most of the cases occurred in the 
age range of 20–35 years old (64.4%) with the gestational age of >28 weeks (65.8%). Of all risk factors 
observed, hypertensive disorders were the most common medical conditions found (45.6%), followed 
by unknown factors (17.8%), and congenital abnormalities (14.2%).
Conclusions: The majority of stillbirth patients are at their optimal reproductive age, nulliparity, and 
have hypertensive disorders during pregnancy, specifically the superimposed preeclampsia subtype. 
Although the prevalence is considerably low, early management of the risk factors, particularly 
hypertensive disorder, is important to prevent its occurrence.

Keywords: Characteristics, prevalence, risk factor, stillbirth

https://doi.org/10.15850/amj.v9n4.2646



Althea Medical Journal. 2022;9(4)

229

external/obstetric, and unknown origin. 
Other classification systems are also available: 
Relevant Condition at Death (ReCoDe), Causes 
of Death and Associated Conditions (CODAC), 
Tulip, Perinatal Society of Australia and 
New Zealand-Perinatal Death Classification 
(PSANZ-PDC), and International Classification 
of Diseases 10th Revision-Perinatal Mortality 
(ICD-PM).2,6,7 

Stillbirth affects the mother and the family 
psychologically, and researches have shown 
that higher depression and anxiety level were 
found in women with prior history of stillbirth 
compared to women with no prior history.5 
This study aimed to describe the prevalence, 
baseline, and risk factor characteristics of 
stillbirth among singleton pregnancies at a 
tertiary hospital from 2017–2020. 

Methods

This study was a descriptive cross-sectional 
study; samples were collected from the 
Department of Obstetrics and Gynecology, 
Dr. Hasan Sadikin General Hospital Bandung 
by total sampling. Inclusion criteria were 
stillbirth medical records with complete 
baseline characteristics data, 2nd–3rd trimester 
pregnancies, and singleton pregnancies. 
Medical records with incomplete baseline data 
and multiple gestations (twin pregnancies) 
were excluded from this study.

Baseline characteristics consisted of 
maternal age (years), gestational age (weeks), 
obstetrical status (parity and abortion), on-site 
body mass index, and a number of risk factors. 
The risk factors assessed were hypertensive 
disorders in pregnancy that comprised of 
preeclampsia, superimposed preeclampsia, 
eclampsia, and chronic hypertension,8,9 
intrauterine infection, diabetes mellitus, 
that further subdivided into type 1 and type 
2, amniotic fluid abnormalities, anemia in 
pregnancy, premature rupture of membrane 
(PROM), intrauterine growth restriction 
(IUGR), antepartum hemorrhage (APH), 
placental abruption, umbilical cord prolapse. 
Congenital abnormalities, specifically major 
type, were based on the National Birth Defects 
Prevention Network (NBDPN) and defined as 
abnormalities that required surgery or medical 
treatment, had a serious impact on health, 
or had a significant impact on appearance.10 
Unknown/unexplained factor is defined as the 
absence of any clinical risk factors or causes 
of death based on the antenatal examination, 
placental, and fetal autopsy.2,11

Data from medical records were collected 

after obtaining ethical clearance from the 
Research Ethics Committee Universitas 
Padjadjaran (739/UN6.KEP/EC/2021) and 
Dr. Hasan Sadikin General Hospital Bandung 
(LB.02.01/X/2.2.1/19986/2021). Eligible 
data were processed by using Microsoft Excel 
2019 and IBM® SPSS® 25.

Results

There were 385 stillbirth cases recorded 
from a total of 10,166 births counted from 
2017 to 2020. Of 385 stillbirth cases, 92 data 
were not available, and 74 data did not meet 
the inclusion criteria, with the distribution as 
follows: three twin pregnancies, one data with 
unknown maternal age, five patients with a 
gestational age of <20 weeks (miscarriage), 11 
patients with unknown gestational age, and 54 
incorrect/inaccurate data. Hence, the rest 219 
subjects were used, making the prevalence of 
stillbirth in this study 2.2%, with a case rate of 
22 per 1,000 births.

Baseline characteristics (Table 1) showed 
the highest cases count among patients aged 
20–35 years old (n=141, 64.4%) and >28 
weeks’ gestational age group (n=144, 65.8%). 
The mean and median for the maternal age were 
30 and 31 years old, respectively. Meanwhile 
for the gestational age, both the mean and 
median were 30 years old. Obstetrical status 
showed high cases among zero parities and 
one parity. Most of the patients had never had 
an abortion. Data regarding the body mass 
index (BMI) of patients were obtained from 
the measurement done in the first 12 hours 
since the patients admitted to the hospital, 
not from the pre-pregnancy nor first trimester 
BMI due to the absence of data.

Based on the risk factor characteristics, 
most patients had hypertensive disorders 
during pregnancy (n=100, 45.6%), which 
further classified into preeclampsia (n=27, 
12.3%), superimposed preeclampsia (n=55, 
25.1%), eclampsia (n=16, 7.3%), and chronic 
hypertension (n=2, 0.9%); followed by 
unknown origin (n=39, 17.8%) the diagnosis 
was made from the absence of any pathological 
evidence from the antenatal history, physical 
and laboratory examinations (as indicated) 
and fetal autopsy; and major congenital 
abnormalities (n=31, 14.2%). 

Some abnormalities in this study were 
classified based on the organs involved, 
such as (1) neural tube defects (NTDs) 
comprised of anencephaly, hydranencephaly, 
corpus callosum agenesis, and alobar 
holoprosencephaly, (2) congenital heart 

David Immanuel et al.:  Risk Factor of Stillbirth among Pregnant Women at Dr. Hasan Sadikin General Hospital 
Bandung from 2017–2020



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230     Althea Medical Journal December 2022

Table 1 Baseline Characteristics of Mothers who Had a Stillbirth at the Department of
    Obstetrics & Gynecology, Dr. Hasan Sadikin General Hospital Bandung 2017–2020

Characteristics
Results (n= 219)

n % x ̅(min-max)
Age (years)
     <20
     20–35 
     >35

14
141
64

6.4
64.4
29.2

30 (14 – 44)

Gestational age (weeks)
     20–28
     >28

75
144

34.2
65.8

 30 (20 – 42)

Obstetrical status
     Parity
          0
          1
          2
          ≥3
     Abortion
          0
          1
          2
          ≥3

67
66
56
30

181
29
9
0

30.6
30.1
25.6
13.7

82.7
13.2
4.1
0

Body mass index* (kg/m2)
     <18.5 
     18.5–22.9 
     23–24.9 
     ≥25 

20–28 weeks n=75
1

33
15
26

>28 weeks n=144
0

27
22
95

26.9 (17.6 – 50.4)

defects (CHD): Tetralogy of Fallot (ToF), 
ectopia cordis, and fetal pericardial effusion, 
and (3) congenital gastrointestinal disorders 
consisting gastroschisis, duodenal atresia and 
congenital diaphragmatic hernia. The results 
showed hydrops fetalis outnumbered the 
other abnormalities subtypes (n=12, 5.5%) 
(Table 2). Assessment of the distribution of 
risk factors showed the highest cases among 
patients with single risk factors (Table 3). 

 
Discussion

The prevalence of stillbirth in this study is 
2.2%, resulting in the SBR of 22 cases per 1,000 
births. This result is almost two times higher 
than the goal set by Sustainable Development 
Goals (SDGs); with an SBR target of fewer than 
12 cases per 1,000 births. The mean age of the 
patients included in this study is 30 years old. 
Approximately 64.4% of cases occurred in the 
age range of 20–35 years, corresponding with 
the previous study done on the nearby region, 
Tasikmalaya district, West Java Province 
in 2017, where the highest occurrence of 
stillbirth belong to the population between 20–

35 years old with the percentage of 68.4%.12 
Other studies done in Nepal from 2017–2019 
and Ethiopia in 2018 showed similar results, 
where most of the cases have occurred at the 
age range of 21–30 years old (67.1%) and 20–
34 years old (77.7%), respectively.13,14 

Stillbirth at 28 weeks gestation or after 
was more frequently seen in this study with a 
median of 30 weeks. Similar results were also 
reported in the United States of America from 
March 2020–September 2021, 55.8% with 
a median of 29 weeks.15 Obstetrical status 
based on the previous study from Tasikmalaya 
district in 2017 and Global Network Sites from 
2010–2019 both showed the highest cases 
count among primiparity and multiparity 
rather than nulliparity, meanwhile,  nulliparity 
accounted for the highest cases count (30.6%) 
in this study.12,16 BMI was measured in the first 
12 hours since the patient was admitted to the 
hospital. Pre-pregnancy and first-trimester 
anthropometry data were unavailable since 
most of the patients got antenatal care outside 
the study location, and the rest of them got no 
antenatal care.

Almost half of the patients in this study had 



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231

Table 2 Risk Factor of Stillbirth at the Department of Obstetrics and Gynecology Dr. Hasan 
 Sadikin General Hospital Bandung 2017–2020

Risk Factors Subtypes
Results

n %

Unknown/unexplained 39 17.8
Maternal Hypertensive disorders in pregnancy

     Preeclampsia
     Superimposed preeclampsia
     Eclampsia
     Chronic hypertension

27
55
16
2

12.3
25.1
7.3
0.9

Intrauterine infection
     Unspecified 2 0.9
Diabetes mellitus
     Type I
     Type II

0
1

0
0.5

Amniotic fluid abnormalities
     Oligohydramnios
     Polyhydramnios

2
1

0.9
0.5

Anemia
     Unspecified
     Iron deficiency

6
3

2.7
1.4

PROM 28 12.8
IUGR 16 7.3
Unspecified APH 1 0.5

Placental Placental abruption with APH
Placenta previa with APH
Placental abruption without APH

10
6
8

4.6
2.7
3.7

Cord Cord prolapse 2 0.9
Fetal Congenital abnormalities

     Hydrops fetalis
     Dandy Walker syndrome

12
1

5.5
0.5

Neural tube defects
     Anencephaly
     Hydranencephaly
     Corpus callosum agenesis
     Alobar holoprosencephaly

3
1
1
2

1.4
0.5
0.5
0.9

Congenital heart disorders
     Tetralogy of Fallot
     Ectopia cordis
     Fetal pericardial effusion

1
2
1

0.5
0.9
0.5

Congenital gastrointestinal disorders
     Gastroschisis
     Duodenal atresia
     Congenital diaphragmatic hernia

2
1
1

0.9
0.5
0.5

Macrosomia 2 0.9
Megavesica 1 0.5

Others Previous cesarean section
Obstetric complication (asphyxia)
Maternal sepsis

6
2
1

2.7
0.9
0.5

Note: PROM= Premature rupture of membrane, IUGR= Intrauterine fetal growth restriction, APH= Antepartum hemorrhage, 
unspecified= no information regarding the etiology or underlying cause.

David Immanuel et al.:  Risk Factor of Stillbirth among Pregnant Women at Dr. Hasan Sadikin General Hospital 
Bandung from 2017–2020



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232     Althea Medical Journal December 2022

hypertensive disorders during pregnancy that 
werer further subdivided into preeclampsia, 
superimposed preeclampsia (preeclampsia 
preceded by chronic hypertension), eclampsia, 
and chronic hypertension. This finding is in 
accordance with another study conducted in 
the United States of America which showed that 
most of  the stillbirth patients had hypertensive 
disorders (20.9%) and were subdivided into 
chronic hypertension and pregnancy–related 
hypertension, which consisted of gestational 
hypertension, superimposed preeclampsia, 
preeclampsia, HELLP syndrome, and 
eclampsia.15 Similar result was reported 
from a cross sectional research conducted 
among Middle-East population in 2015 with 
a percentage of 22.5%.17 However, different 
results were reported by studies from 
Tasikmalaya district, West Java Province, 
and a systematic review involving 85 reports 
across 50 countries worldwide in 2017, that 
most of the stillbirth patients had unknown/
unexplained stillbirths, with a percentage 
of 56.7% and ranging from 32.1% to 43.7%, 
respectively.6,12

In this study, 17.8% of patients had no 
known etiology or possible cause for the 
occurrence of stillbirth. This finding is different 
from the studies previously mentioned which 
unknown origin was the leading factor.6,12 
Different results were also reported by a study 
in Nepal from 2017–2019, where one-third 
of stillbirth patients had unknown causes or 
possible causes of stillbirth.13

Congenital abnormalities affect 31 (14.2%) 
stillbirth patients in this study. This finding is 
higher from the previous systematic review 
involving several countries worldwide, with 
an overall percentage of 11%, but lower than 
what was reported from a study in Qatar with 
the percentage of 21.6%.6,17

Superimposed preeclampsia is a condition 
where preeclampsia is preceded by chronic 
hypertension (hypertension beginning before 
20 weeks gestation and or persisting after 
12 weeks postpartum).8 The ‘conversion’ 
from chronic hypertension (uncomplicated 

state) to preeclampsia remains unclear. 
However, several factors were suspected to 
be involved in its pathological process, such 
as the imbalance between the pro-angiogenic 
factors: vascular endothelial growth factor 
(VEGF) & placental growth factor (PlGF); 
and anti-angiogenic factors: soluble Fms like 
tyrosine kinase-1 (sFlt-1) & soluble endoglin 
(sEng), it is also mentioned that the preexisting 
endothelial dysfunction due to the vascular 
shear stress and endothelial injury in women 
with longstanding (chronic) hypertension may 
contribute to the imbalance of the previously 
mentioned angiogenic factors and thus 
exacerbate the occurrence of preeclampsia.18,19 

Preeclampsia could lead to stillbirth by 
several mechanisms: abnormality or pathology 
of placentation in preeclampsia characterized 
by the defect in spiral artery remodeling, 
abnormal trophoblastic invasion, along with 
the increased vascular resistance could lead 
to placental ischemia and fetal hypoperfusion; 
hence, several adverse effects could ensue 
such as IUGR, fetal distress, and stillbirth.20

This study has several limitations. Previous 
data regarding the maternal and risk factor 
characteristics of stillbirth in Indonesia 
were not available. Hence, the similarity and 
comparison between the result in this study 
and data before 2017 could not be concluded. 
This study was also single–centered, which 
the results might not represent the actual 
condition in West Java Province and Indonesia. 
Pre-pregnancy BMI could not be obtained 
since the subjects had prenatal/antenatal care 
(PNC/ANC) outside the study location.

In conclusion, the prevalence of stillbirth 
in this study is considerably low. Of all 
recorded factors available, most patients 
have hypertensive disorders, specifically 
superimposed preeclampsia subtype, 
followed by an unknown factor and congenital 
abnormalities. Among the abnormalities, 
hydrops fetalis accounts for the highest 
proportion. Multi-centered study with 
a prolonged period is recommended to 
increase the study population. Thus more 

Table 3 Risk Factor(s) Distribution of Stillbirth

Number of Risk Factor(s)
Results (n = 219

n %

0
1
2
3

39
141
32
7

17.8
64.4
14.6
3.2



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precise results can be obtained. Analysis of 
the correlation between the risk factor and 
stillbirth occurrence is also recommended to 
establish further and differentiate significant 
and possible risk factor(s) of stillbirth.

 
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David Immanuel et al.:  Risk Factor of Stillbirth among Pregnant Women at Dr. Hasan Sadikin General Hospital 
Bandung from 2017–2020