Risk factors for stillbirth in Freetown, Sierra Leone – The StillFree study

Background Every year 1.9 million stillbirths occur worldwide, with low- and lower middle-income countries accounting for 98% of this burden. In Sierra Leone data on stillbirths’ risk factors are limited and conflicting. This study aims to identify maternal and fetal risk factors associated with stillbirth at the Princess Christian Maternity Hospital (PCMH) in Freetown, Sierra Leone. Methods a prospective case-control study was conducted from April to October 2023 at PCMH. The study included 200 women diagnosed with stillbirths (cases) and 200 women with live births (controls). Data on demographic, medical history, clinical and delivery course were collected. Two backward stepwise multivariable logistic regression models were performed to identify risk factors, including model 1 assessing pre-hospital and antepartum risk factors for stillbirth and Model 2 focusing on intrapartum risk factors in the subgroup of cases admitted with a live fetus. Results The analysis of antepartum risk factors (Model 1) revealed that advanced maternal age (aOR 1.071; 95% CI 1.025–1.119; p = 0.002), being referred from another facility (aOR 4.397; 95% CI 2.643–7.313; p < 0.001), low antenatal care attendance (aOR 1.883; 95% CI 1.445–1.976; p = 0.015), malaria infection (aOR 10.385; 95% CI 1.279–84.299; p = 0.028), abruptio placentae (aOR 15.491; 95% CI 3.469–69.184; p < 0.001), and prematurity (aOR 1.8; 95% CI 1.734–1.871; p < 0.001) were significant risk factors for stillbirth. Furthermore, factors significantly associated with intrapartum stillbirth (Model 2) were meconium-stained amniotic fluid (aOR 10.071; 95% CI 3.008–33.721; p = < 0.001), oxytocin augmentation (aOR 31.721; 95% CI 2.145–49.018; p = 0.012), and low birth weight (aOR 1.434; 95% CI 1.223–1.448; p = 0.015). The use of the partograph was additionally found to be protective against intrapartum stillbirth (aOR 0.114; 95% CI 0.032–0.404; p < 0.001). Conclusion Stillbirths at PCMH are linked to a combination of pre- and in-hospital care elements. Key areas for intervention include optimizing the referral system, enhancing the quality and accessibility of antenatal care, and improving intrapartum management through effective labor monitoring and standardized use of oxytocin. These findings provide a roadmap for context-specific strategies to reduce stillbirths in Freetown and similar resource-limited settings.