{ "abstract": "Background: Globally, an estimated 1.9 million stillbirths occur annually, yet significant knowledge gaps exist regarding the causes of stillbirths, particularly in high-burden regions. We investigated fetal and maternal conditions causing stillbirths in seven countries in sub-Saharan Africa and South Asia and described missed opportunities for prevention. Methods: Child Health and Mortality Prevention Surveillance (CHAMPS) identified stillbirths at sites in Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa. We asked families for consent to conduct minimally invasive tissue sampling (MITS) from December 2016 to December 2023. An expert panel reviewed test results, clinical information, and verbal autopsy data and assigned fetal and maternal conditions leading to stillbirths and identified missed opportunities for prevention. Findings: A cause of death (fetal or maternal condition) was determined for 94% (2342/2492) of stillbirths; the most frequent condition in the fetus was intrauterine hypoxia (75%, 1864/2492) across all sites, resulting from either maternal condition (49%, 922/1864) or placental causes (33%, 610/1864). Congenital infections were determined to be the cause of 9% (228/2492) of stillbirths, accounting for the highest proportion in South Africa (31%, 96/306). Group B Streptococcus, Escherichia coli, and Enterococcus faecalis were the most common causative pathogens. Congenital birth defects caused 9% (227/2492) overall and were most common in Ethiopia (24%, 136/568). Primary maternal conditions were identified in 72%, most often placental complications (18%, 446/2492) and maternal hypertension (17%, 414/2492). Complications of placenta, cord and membranes were more common in Mali (43%, 92/212) while maternal medical and surgical conditions were most frequently observed in South Africa (40%, 121/306) and Bangladesh (39%, 158/405). Most (72%, 1808/2492) causes of stillbirth were considered preventable, with heterogeneity observed across sites on the recommended prevention strategies. Interpretation: Complications of pregnancy or delivery accounted for most stillbirths across all sites, with intrauterine hypoxia identified as the predominant fetal condition highlighting widespread and persistent gaps in the timely identification and management of maternal and placental conditions during antenatal and obstetric care across sites in Africa and South Asia. At the same time, substantial geographic variation in causes and prevention opportunities, including for infections and birth defects, underscored the need for locally tailored strategies. Strengthening facility-based care alongside targeted interventions based on site-specific patterns, will be critical to reducing the stillbirth burden in these high-priority regions. Funding: The Gates Foundation", "abstract_shown": true, "affiliations": [ "International Center for Diarrhoeal Diseases Research (icddr, b), Dhaka, Bangladesh", "Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America", "Emory Global Health Institute, Emory University, Atlanta, Georgia, United States of America", "The Africa Research Collaborative (the ARC), Freetown, Sierra Leone", "World Hope International, Makeni, Sierra Leone", "Centre pour le Développement des Vaccins (CVD-Mali), Ministère de la Santé, Bamako, Mali", "Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America", "South African Medical Research Council Vaccines and Infectious Diseases Analytics (VIDA) Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa", "Faculty of Health Sciences, Wits Infectious Disease and Oncology Research Institute, University of the Witwatersrand, Johannesburg, South Africa", "Wits Department of Obstetrics & Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa", "Kenya Medical Research Institute (KEMRI), Kisumu, Kenya", "Kisumu County of Department of Health, Kisumu, Kenya", "Centro de Investigação em Saúde de Manhiça [CISM], Maputo, Mozambique", "Instituto Nacional de Saúde [INS], Maputo, Mozambique", "ISGlobal - Hospital Clínic, Universitat de Barcelona, Barcelona, Spain", "Institutó Catalana de Recerca i Estudis Avançats [ICREA], Barcelona, Spain", "Pediatrics Department, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues, Barcelona, Spain", "CIBER de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain", "College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia", "Department of Infectious Disease Epidemiology and International Health, London School of Hygiene & Tropical Medicine, London, United Kingdom", "Ayder Specialized Comprehensive Hospital, Mekelle University, Mekele, Ethiopia", "Liverpool School of Tropical Medicine (LSTM), Liverpool, England", "Addis Ababa University, Addis Ababa, Ethiopia", "Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America" ], "article_type": "Research Article", "arxiv": null, "author_total": 44, "authors": [ { "affs": [ 0 ], "name": "Afruna Rahman" }, { "affs": [ 1, 2 ], "name": "Kyu Han Lee" }, { "affs": [ 0 ], "name": "Shams El Arifeen" }, { "affs": [ 0 ], "name": "Mohammad Zahid Hossain" }, { "affs": [ 0 ], "name": "Atique Iqbal Chowdhury" }, { "affs": [ 0 ], "name": "Muntasir Alam" }, { "affs": [ 0 ], "name": "Afsana Afrin", "orcid": "0009-0006-5108-9801" }, { "affs": [ 3 ], "name": "Ikechukwu Udo Ogbuanu" }, { "affs": [ 4 ], "name": "Solomon Samura" }, { "affs": [ 3 ], "name": "Erick Kaluma", "orcid": "0009-0009-6416-6724" }, { "affs": [ 3 ], "name": "Julius Ojulong", "orcid": "0000-0003-2200-8954" }, { "affs": [ 5 ], "name": "Samba Sow" }, { "affs": [ 5 ], "name": "Adama Mamby Keita" }, { "affs": [ 6 ], "name": "Milagritos D. Tapia" }, { "affs": [ 6 ], "name": "Kiranpreet Kaur Chawla" }, { "affs": [ 6 ], "name": "Karen Kotloff" }, { "affs": [ 7, 8 ], "name": "Shabir A. Madhi" }, { "affs": [ 7 ], "name": "Sana Mahtab" }, { "affs": [ 7 ], "name": "Yasmin Adam" }, { "affs": [ 9 ], "name": "Amy Wise", "orcid": "0000-0001-5182-9060" }, { "affs": [ 7, 8 ], "name": "Ziyaad Dangor" }, { "affs": [ 10 ], "name": "Christopher Mugah" }, { "affs": [ 11 ], "name": "Elizabeth Oele" }, { "affs": [ 10 ], "name": "Richard Omore", "orcid": "0000-0003-3702-3030" }, { "affs": [ 10 ], "name": "Aggrey K. Igunza", "orcid": "0000-0002-5841-5431" }, { "affs": [ 11 ], "name": "Dickens Onyango" }, { "affs": [ 12, 13, 14 ], "name": "Inacio Mandomando" }, { "affs": [ 12, 14, 15, 16, 17 ], "name": "Quique Bassat", "orcid": "0000-0003-0875-7596" }, { "affs": [ 12, 14 ], "name": "Sara Ajanovic" }, { "affs": [ 12, 14 ], "name": "Rosauro Varo", "orcid": "0000-0003-4282-5572" }, { "affs": [ 14 ], "name": "Elisio Xerinda" }, { "affs": [ 18 ], "name": "Nega Assefa" }, { "affs": [ 19 ], "name": "J. Anthony G. Scott", "orcid": "0000-0001-7533-5006" }, { "affs": [ 18, 19, 20, 21 ], "name": "Lola Madrid" }, { "affs": [ 20 ], "name": "Melisachew M. Yeshi" }, { "affs": [ 22 ], "name": "Fikremelekot Temesgen", "orcid": "0000-0001-7927-2153" }, { "affs": [ 2 ], "name": "Lucy Liu" }, { "affs": [ 2 ], "name": "Portia Mutevedzi" }, { "affs": [ 23 ], "name": "Dianna M. Blau", "orcid": "0000-0002-1253-198X" }, { "affs": [ 10, 21 ], "name": "Victor Akelo" }, { "affs": [ 2 ], "name": "Robert F. Breiman" }, { "affs": [ 2 ], "name": "Cynthia G. Whitney", "orcid": "0000-0002-1056-3216" }, { "affs": [ 0, 1 ], "name": "Emily S. Gurley", "orcid": "0000-0002-8648-9403" }, { "name": "for the CHAMPS Consortium" } ], "bibtex": "https://research.draconitic.com/paper/965814ybfc1mx.bib", "cited_by": 0, "doi": "10.1371/journal.pgph.0005235", "fulltext_url": "https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0005235", "id": "965814ybfc1mx", "issns": [ "2767-3375" ], "landing_url": "https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0005235", "language": "en", "licence": "CC0-1.0", "licence_label": "CC0", "licence_source": "article", "licence_url": "https://creativecommons.org/publicdomain/zero/1.0/", "metadata_licence": null, "native_subjects": [ [ "heading", "Anatomy" ], [ "heading", "Bacterial diseases" ], [ "heading", "Biology and Life Sciences" ], [ "heading", "Blood Pressure" ], [ "heading", "Cell Biology" ], [ "heading", "Developmental Biology" ], [ "heading", "Embryology" ], [ "heading", "Fetal Death" ], [ "heading", "Group B streptococcal infection" ], [ "heading", "Health Care" ], [ "heading", "Health Care Facilities" ], [ "heading", "Hypertension" ], [ "heading", "Hypertensive Disorders in Pregnancy" ], [ "heading", "Hypoxia" ], [ "heading", "Infectious diseases" ], [ "heading", "Maternal Health" ], [ "heading", "Medical conditions" ], [ "heading", "Medicine and Health Sciences" ], [ "heading", "Medicine and health sciences" ], [ "heading", "Obstetrics and Gynecology" ], [ "heading", "Placenta" ], [ "heading", "Pregnancy" ], [ "heading", "Pregnancy Complications" ], [ "heading", "Reproductive System" ], [ "heading", "Research Article" ], [ "heading", "Stillbirths" ], [ "heading", "Vascular Medicine" ], [ "heading", "Women's Health" ], [ "openalex", "2735|Global Maternal and Child Health" ], [ "plos", "/Biology and life sciences/Anatomy/Reproductive system/Placenta" ], [ "plos", "/Biology and life sciences/Cell biology/Hypoxia" ], [ "plos", "/Biology and life sciences/Developmental biology/Embryology/Placenta" ], [ "plos", "/Medicine and health sciences/Anatomy/Reproductive system/Placenta" ], [ "plos", "/Medicine and health sciences/Health care/Health care facilities" ], [ "plos", "/Medicine and health sciences/Medical conditions/Infectious diseases/Bacterial diseases/Group B streptococcal infection" ], [ "plos", "/Medicine and health sciences/Vascular medicine/Blood pressure/Hypertension/Hypertensive disorders in pregnancy" ], [ "plos", "/Medicine and health sciences/Women's health/Maternal health/Pregnancy/Hypertensive disorders in pregnancy" ], [ "plos", "/Medicine and health sciences/Women's health/Maternal health/Pregnancy/Pregnancy complications/Fetal death" ], [ "plos", "/Medicine and health sciences/Women's health/Obstetrics and gynecology" ], [ "plos", "/Medicine and health sciences/Women's health/Obstetrics and gynecology/Pregnancy/Hypertensive disorders in pregnancy" ], [ "plos", "/Medicine and health sciences/Women's health/Obstetrics and gynecology/Pregnancy/Pregnancy complications/Fetal death" ], [ "plos", "/Medicine and health sciences/Women's health/Obstetrics and gynecology/Stillbirths" ] ], "openalex": "W7223891376", "pdf_url": "https://journals.plos.org/globalpublichealth/article/file?id=10.1371/journal.pgph.0005235&type=printable", "pmcid": "PMC13712675", "pmid": "42945338", "published": "2026-10-27", "publisher": "Public Library of Science", "ris": "https://research.draconitic.com/paper/965814ybfc1mx.ris", "sources": [ { "first_seen": "2026-10-30T12:17:17Z", "native_id": "10.1371/journal.pgph.0005235", "source": "plos", "url": "https://journals.plos.org/globalpublichealth/article?id=10.1371/journal.pgph.0005235" }, { "first_seen": "2026-10-31T12:23:12Z", "native_id": "PMC13712675", "source": "pmc", "url": "https://doi.org/10.1371/journal.pgph.0005235" } ], "subjects": [ { "field": "biology", "origin": "heading:Cell Biology", "subfield": "cell-biology" }, { "field": "biology", "origin": "heading:Developmental Biology", "subfield": "developmental-biology" }, { "field": "medicine", "origin": "heading:Infectious diseases", "subfield": "infectious-disease" }, { "field": "medicine", "origin": "heading:Anatomy", "subfield": "physiology" }, { "field": "medicine", "origin": "plos:women's health", "subfield": "reproductive-child" } ], "title": "Causes of stillbirth in sub-Saharan Africa and South Asia: Findings from Child Health and Mortality Prevention Surveillance, 2016–2023", "title_text": "Causes of stillbirth in sub-Saharan Africa and South Asia: Findings from Child Health and Mortality Prevention Surveillance, 2016–2023", "type": "peer-reviewed", "updated_at": "2026-10-31T12:23:12Z", "url": "https://research.draconitic.com/paper/965814ybfc1mx", "venue": "PLOS Global Public Health", "versions": [] }