Obesity Linked to Higher Risk of Stillbirth: Insights from the Tanzania Demographic and Health Survey

doi:10.21203/rs.3.rs-5141583/v1

Background: Obesity among women of reproductive age is an escalating public health concern. This study aimed to assess the link between body mass index (BMI) and the risk of stillbirth among women of reproductive age in Tanzania.

Method: The study utilized the 2022 Tanzania Demographic and Health Survey and Malaria Indicator Survey data, encompassing a weighted sample of 2,218 women of reproductive age. Bivariate and multivariable binary logistic regression analyses were employed to determine the association between maternal BMI and stillbirth.

Results: The mean age of the participants was 32.7 years (SD = 8.7). Of the 2,218 women aged 15-49 years, 120 (5.4%) had ever experienced at least one stillbirth. The prevalence of overweight and obesity was 22.6% and 14.3%, respectively. The risk of stillbirth increased with higher BMI categories: 4.2% among women with BMI <25 kg/m², 6.2% among those with BMI 25─29.0 kg/m², and 9.8% among those with BMI ≥30 kg/m². The differences in the prevalence of stillbirth across these BMI categories were statistically significant (p < 0.001). After controlling for confounders, women with obesity had more than twice the risk of stillbirth compared to those with normal weight (aOR=2.22, 95% CI: 1.32–3.72).

Conclusion: This study found that over one-third of women of reproductive age in Tanzania were either overweight or obese. It also found that an increase in maternal BMI was associated with a higher risk of stillbirths. We therefore recommend weight management strategies both before and during pregnancy to reduce the risk of adverse pregnancy outcomes.

Stillbirth

Obesity

overweight

Women

Reproductive Age

Tanzania

Stillbirth, a significant adverse pregnancy outcome with serious public health implications, occurs when a baby dies either before labor (antepartum) or during labor and delivery (intrapartum) after at least 28 weeks of gestation [1]. Globally, over 5,000 babies are stillborn daily, resulting in about 1.9 million stillbirths annually. From 2000 to 2019, the global stillbirth rate declined by 2.3 percent annually, slower than the 2.9 percent reduction in neonatal mortality [2].

Stillbirth rates vary significantly worldwide, with three-quarters occurring in sub-Saharan Africa and Southern Asia. While Europe, North America, Australia, and New Zealand have a rate of 1 in 321, accounting for just 2% of global stillbirths, sub-Saharan Africa has the highest rate at 1 in 46 live births, contributing 42% of the global burden [3]. Tanzania has a high stillbirth rate, with 22 per 1,000 births nationally and 27.7 per 1,000 in urban hospitals in Dar es Salaam [4, 5]. Notably, 88.4% of these cases are pre-facility, highlighting the urgent need for better access to maternal care. Despite efforts, progress in reducing stillbirths has been slow, threatening the achievement of the Sustainable Development Goal target of 12 stillbirths per 1,000 births by 2030 [6].

Most stillbirths result from preventable causes. Investing in maternal health, particularly through preconception care, high-quality antenatal services, and skilled birth attendance, is crucial in addressing and ultimately preventing stillbirths. The government of Tanzania has prioritized improving access to quality maternal and child health services, particularly in rural and underserved areas, by removing financial barriers and increasing the number of health facilities [7]. This effort is coupled with the expansion of antenatal care, skilled birth attendance, and postnatal care services to detect and manage complications that could lead to stillbirths [7].

Through the Ministry of Health, the government promotes birth preparedness and complication readiness among pregnant women and their families by educating them on antenatal care, recognizing danger signs, and ensuring access to health facilities [8]. Efforts have also been made to strengthen emergency obstetric care services by training providers, equipping facilities, and ensuring the availability of essential supplies [9]. Despite these efforts, the stillbirth rate remains alarmingly high.

Previous studies have identified various maternal and fetal risk factors associated with stillbirth. Maternal risk factors include a history of stillbirth [10, 11], gestational hypertension [10–13], advanced maternal age [11, 12, 14], poverty [12, 14, 15], and inadequate antenatal care utilization [11, 15]. Fetal risk factors include being small for gestational age [11, 12, 16], placental or fetal infections [13], congenital malformations [17], mal-presentation [16].

Obesity among women of reproductive age is an escalating public health concern. The connection between maternal obesity and stillbirth remains insufficiently investigated, even as the number of women of reproductive age with above-average body mass index (BMI) continues to rise in low-resource countries, including Tanzania [18]. Understanding the contribution of obesity to the incidence of stillbirth in the country is crucial. It will guide governmental efforts to strengthen pre-conception care by advising women intending to become pregnant to reduce their BMI if they are obese. Therefore, this study aimed to assess the link between maternal BMI and the risk of stillbirth among women of reproductive age in Tanzania.

Study design

Tanzania has conducted seven Demographic and Health Surveys (DHS) since the first one in 1991-92. The most recent survey was completed in 2022, which also included a Malaria Indicator Survey (MIS) component. These surveys provide critical data for monitoring and evaluating health and demographic trends in the count [19]. This study is based on a secondary analysis of the 2022 Tanzanian DHS data.

Variables

The outcome variable for this study is stillbirth, defined as the fetal death occurring at or after 28 weeks of gestation in any pregnancy recorded in the woman’s pregnancy history (WHO 2014). A pregnancy history is a comprehensive record of all pregnancies a woman has experienced, encompassing live births, stillbirths, miscarriages, and abortions [20]. The stillbirth rate was computed as the number of stillbirths divided by the number of pregnancies lasting 28 or more weeks, expressed per 1,000 [19]. The main explanatory variable is maternal BMI, computed by dividing body weight in kilograms by the square of height in meters (kg/m²). Maternal BMI was categorized into three groups: normal weight (< 25 kg/m²), overweight (25 to 29.9 kg/m²), and obesity (≥ 30 kg/m²) [21].

The present study included three categories of covariates: demographic characteristics, which encompassed the woman’s age, marital status, and level of formal education attained; social and economic factors, including household wealth, place of residence (urban or rural), and proximity to the nearest health facility; and pregnancy and health history, which covered histories of multiple pregnancy, hypertension, and miscarriages (Fig. 1).

INSERT FIGURE 1 HERE

Figure 1

Conceptual framework illustrating the relationship between maternal body mass index (BMI) and the risk of stillbirth

Household wealth was estimated using a wealth index based on consumer goods owned and housing characteristics. Principal component analysis was used to compute household scores, which were then used to rank each household. The scores were divided into five categories to create the wealth quintile [19].

Inclusion criteria

The inclusion criteria for this study required participants to have a documented pregnancy history with a gestational age of at least 28 weeks and to have complete data available for estimating their BMI. Out of 2,967 participants with BMI data available, 749 were excluded due to missed data on birth outcomes. Ultimately, 2,218 women from the 2022 Tanzania DHS met the inclusion criteria and were included in the analysis.

Data analysis

Descriptive statistics were summarized using frequencies and percentages for categorical variables and means with standard deviations (SD) for continuous variables, as appropriate. Associations between the risk of stillbirth and explanatory variables were assessed using Pearson's chi-square tests [22]. Bivariate logistic regression analyses were performed to evaluate the effect of each explanatory variable on the outcome. Multivariable logistic regression models were then fitted to control for potential confounders and provide adjusted estimates [23]. Results are presented using odds ratio (OR) and adjusted odds ratio (aOR), along with their 95% confidence intervals (CIs) and p-values.

The goodness of fit for the multivariable model was assessed using the Hosmer-Lemeshow test with the Stata command ‘estat gof, group(10)’ [24]. The results indicated a good fit for the data: X² (8) = 12.48, p = 0.131. The final model correctly classified 94.6% of the cases. Statistical significance was set at p-values < 0.05. Data preparation and analysis were conducted using Stata version 17.0 (Stata Corp LP, College Station, Texas, USA).

Participants’ baseline characteristics

This study included 2,218 women aged 15 to 49, with a mean age of 32.7 years (SD = 8.7). A majority of the participants were rural residents (67.3%), married (53.6%), and had completed primary education (56.9%). Most participants had no known history of hypertension (91.6%) and no history of miscarriage (86.7%). Additionally, 68.5% of participants had no problem accessing healthcare facilities. The prevalence of overweight and obesity was 22.6% and 14.3%, respectively (Table 1).

Table 1

Participants’ baseline characteristics, n = 2,218
Variables	Frequency	Percentage
Body mass index
< 24.9 kg/m²	1,398	63.0
25–29.9 kg/m²	502	22.6
>= 30 kg/m²	318	14.3
Maternal age
15–24 years	467	21.1
25–34 years	811	36.6
35–49 years	940	42.4
Marital status
Single	167	7.5
Married	1,188	53.6
Cohabiting	485	21.9
Widowed/separated	378	17.0
Maternal education
No formal education	386	17.4
Primary	1,262	56.9
Secondary/higher	570	25.7
Household wealth
Poorest	400	18.0
Poorer	413	18.6
Middle	420	18.9
Richer	476	21.5
Richest	509	23.0
Place of residence
Urban	725	32.7
Rural	1,493	67.3
Distance to the facility
A big problem	699	31.5
Not a big problem	1,519	68.5
History of multiple pregnancy
No	2,085	94.0
Yes	133	6.0
Hypertension history
No	2,031	91.6
Yes	187	8.4
History of miscarriage
No	1,922	86.7
Yes	296	13.4

INSERT Table 1 HERE

Maternal BMI and risk of stillbirth

A total of 120 women (5.4%) had ever experienced at least one stillbirth. The risk of stillbirth increased with higher BMI categories: 4.2% among women with normal weight, 6.2% among those who were overweight, and 9.8% among those with obesity. The differences in the prevalence of stillbirth across these BMI categories were statistically significant (p < 0.001) (Table 2).

Table 2

Prevalence of stillbirth
Variables	Frequency	Stillbirth, n (%)	p-value
Overall	2218	120 (5.4)
Body mass index			< 0.001
< 24.9 kg/m²	1,398	58 (4.2)
25–29.9 kg/m²	502	31 (6.2)
>= 30 kg/m²	318	31 (9.8)
Maternal age			0.001
15–24 years	467	16 (3.4)
25–34 years	811	33 (4.1)
35–49 years	940	71 (7.6)
Marital status			0.146
Single	167	5 (3.0)
Married	1,188	75 (6.3)
Cohabiting	485	20 (4.1)
Widowed/separated	378	20 (5.3)
Maternal education			0.984
No formal education	386	21 (5.4)
Primary	1,262	69 (5.5)
Secondary/higher	570	30 (5.3)
Household wealth			0.759
Poorest	400	22 (5.5)
Poorer	413	17 (4.1)
Middle	420	23 (5.5)
Richer	476	29 (6.1)
Richest	509	29 (5.7)
Place of residence			0.722
Urban	725	41 (5.7)
Rural	1,493	79 (5.3)
Distance to the facility			0.441
A big problem	699	34 (4.9)
Not a big problem	1,519	86 (5.7)
History of multiple pregnancy			0.002
No	2,085	105 (5.0)
Yes	133	15 (11.3)
Hypertension history			0.047
No	2,031	104 (5.1)
Yes	187	16 (8.6)
History of miscarriage
No	1,922	98 (5.1)	0.099
Yes	296	22 (7.4)

INSERT Table 2 HERE

Out of 8,113 total births recorded, 142 resulted in stillbirths, corresponding to a rate of 17.5 stillbirths per 1,000 births. The stillbirth rate increased progressively across BMI categories, with 13.3 per 1,000 births among women with normal weight, 21.5 per 1,000 births among overweight women, and 29.6 per 1,000 births among those with obesity (Table 3).

Table 3

Stillbirth rate among women of reproductive age in Tanzania
Variables	Sample, n	Total births	Stillbirth count	Stillbirth per 1000 births
Overall	2218	8113	142	17.5
Body mass index
< 24.9 kg/m²	1,398	5107	68	13.3
25–29.9 kg/m²	502	1858	40	21.5
>= 30 kg/m²	318	1148	34	29.6
Maternal age
15–24 years	467	737	17	23.1
25–34 years	811	2555	36	14.1
35–49 years	940	4821	89	18.5
Marital status
Single	167	273	5	18.3
Married	1,188	4670	92	19.7
Cohabiting	485	1753	21	12.0
Widowed/separated	378	1417	24	16.9
Maternal education
No formal education	386	1902	28	14.7
Primary	1,262	4795	81	16.9
Secondary/higher	570	1416	33	23.3
Household wealth
Poorest	400	1672	29	17.3
Poorer	413	1589	19	12.0
Middle	420	1561	24	15.4
Richer	476	1709	34	19.9
Richest	509	1582	36	22.8
Place of residence
Urban	725	2200	51	23.2
Rural	1,493	5913	91	15.4
Distance to the facility
A big problem	699	2845	42	14.8
Not a big problem	1,519	5268	100	19.0
History of multiple pregnancy
No	2,085	7312	121	16.5
Yes	133	801	21	26.2
Hypertension history
No	2,031	7376	121	16.4
Yes	187	737	21	28.5
History of miscarriage
No	1,922	6920	112	16.2
Yes	296	1193	30	25.1

Age and risk of stillbirths

Women aged 35–49 years exhibited a significantly higher risk of ever experiencing a stillbirth (7.6%) compared to those aged 15–24 years (3.4%), with this difference being statistically significant (p = 0.001) (Table 2). Interestingly, despite the lower overall risk, the stillbirth rate was higher among women aged 15–24 years, with 23.1 deaths per 1000 births, compared to 18.5 deaths per 1000 births among those aged 35–49 years. The lowest stillbirth rate was recorded among women aged 24–35 years, at 14.1 deaths per 1000 births (Table 3).

Pregnancy history, hypertension, and stillbirths

Women with a history of multiple pregnancy were at a significantly higher risk of stillbirth (11.3%) compared to those without such a history (5.0%) (p = 0.002). Additionally, women with a history of hypertension were more likely to have experienced a stillbirth (8.6%) than those without hypertension (5.1%), with this difference also being statistically significant (p = 0.047) (Table 2). Correspondingly, the stillbirth rate was elevated among women with a history of multiple pregnancy (26.2 deaths per 1000 births), hypertension (28.5 deaths per 1000 births), and miscarriage (25.1 deaths per 1000 births) (Table 3).

INSERT Table 3 HERE

Factors associated with the risk of stillbirth

In the unadjusted model, factors associated with a higher risk of stillbirth included obesity (OR = 2.50, 95% CI: 1.58–3.93), maternal age between 35–49 years (OR = 2.30, 95% CI: 1.32–4.01), and a history of multiple pregnancy (OR = 2.40, 95% CI: 1.35–4.25). After adjusting for potential confounders, obesity and a prior history of multiple pregnancy remained significantly associated with an increased likelihood of stillbirth. Specifically, women with obesity had more than twice the risk of stillbirth compared to those with normal weight (aOR = 2.22, 95% CI: 1.32–3.72), while those with a history of multiple pregnancy had nearly twice the odds of experiencing stillbirth (aOR = 1.98, 95% CI: 1.19–3.38) (Table 4).

Table 4

Factors associated with stillbirth
Variables	OR (95% CI)	p-value	aOR (95% CI)	p-value
Body mass index
< 24.9 kg/m²	1		1
25–29.9 kg/m²	1.52 (0.97, 2.38)	0.067	1.44 (0.9, 2.31)	0.130
>= 30 kg/m²	2.50 (1.58, 3.93)	< 0.001	2.22 (1.32, 3.72)	0.003
Maternal age
15–24 years	1		1
25–34 years	1.20 (0.65, 2.20)	0.565	0.98 (0.53, 1.83)	0.962
35–49 years	2.30 (1.32, 4.01)	0.003	1.66 (0.92, 3.01)	0.094
Marital status
Single	1		1
Married	2.18 (0.87, 5.48)	0.096	1.66 (0.65, 4.26)	0.293
Cohabiting	1.39 (0.51, 3.77)	0.514	1.31 (0.47, 3.61)	0.605
Widowed/separated	1.81 (0.67, 4.91)	0.244	1.31 (0.47, 3.67)	0.601
Maternal education
No formal education	1		1
Primary	1.01 (0.61, 1.66)	0.984	1.06 (0.62, 1.8)	0.835
Secondary/higher	0.97 (0.54, 1.71)	0.905	1.07 (0.55, 2.1)	0.842
Household wealth
Poorest	1		1
Poorer	0.74 (0.39, 1.41)	0.358	0.66 (0.34, 1.27)	0.212
Middle	1.00 (0.55, 1.82)	0.988	0.93 (0.5, 1.72)	0.810
Richer	1.11 (0.63, 1.97)	0.709	0.89 (0.48, 1.64)	0.701
Richest	1.04 (0.59, 1.84)	0.898	0.68 (0.35, 1.34)	0.268
Place of residence
Urban	1		1
Rural	0.93 (0.63, 1.37)	0.722	1.22 (0.78, 1.9)	0.379
Distance to the facility
A big problem	1		1
Not a big problem	1.17 (0.78, 1.76)	0.441	1.12 (0.73, 1.73)	0.601
History of multiple pregnancy
No	1		1
Yes	2.40 (1.35, 4.25)	0.003	1.98 (1.10, 3.58)	0.023
Hypertension history
No	1		1
Yes	1.73 (1.00, 3.00)	0.050	1.28 (0.72, 2.30)	0.400
History of miscarriage
No	1		1
Yes	1.49 (0.93, 2.41)	0.101	1.22 (0.74, 2.00)	0.443
Abbreviations: aOR, adjusted odds ratio; OR, odds ratio

INSERT Table 4 HERE

The study revealed that 5 out of every 100 women of reproductive age in Tanzania have experienced at least one stillbirth. Notably, one-third of the study population was classified as either overweight or obese. A higher prevalence of stillbirth was observed among women who were overweight or obese, those of advanced maternal age, women with multiple pregnancies, and those with a history of hypertension or miscarriage. Furthermore, the analysis confirmed a significant association between a women’s BMI and the likelihood of stillbirth, indicating that the risk of stillbirth escalates in parallel with increasing BMI.

The study identified a high stillbirth rate in Tanzania, with 17.5 deaths per 1,000 births. A slightly lower rate of 17.1 per 1,000 live births was reported by a comparable study in sub-Saharan Africa[25]. This slight difference could be attributed to variations in the study populations. The current study focused solely on Tanzania, whereas the previous study encompassed a larger, more diverse population across multiple sub-Saharan African countries, which may have influenced the overall stillbirth rate.

The study also found that older women had a higher lifetime prevalence of experiencing stillbirth compared to younger women. However, younger women exhibited higher rates of stillbirth in the five years preceding the survey. This discrepancy could be explained by the nature of the study, which recorded stillbirth experiences over the course of a woman's lifetime. As older women typically have had more pregnancies, they are more likely to have encountered stillbirth at some point. In contrast, the majority of recent births occurred among younger women, contributing to their higher stillbirth rates in the more recent period. Similar findings have been reported in a study involving six sub-Saharan countries [26].

The study further revealed that women with a history of multiple pregnancies had a significantly higher prevalence of stillbirth compared to those without such a history, likely due to the fact that a substantial proportion of multiple pregnancies do not reach full term(27). Given that multiple pregnancies are typically identified during ANC visits, it is crucial to provide additional, specialized care to these women to prevent avoidable stillbirths. To enhance outcomes, well-structured health interventions, including frequent ANC visits for close monitoring, are essential in supporting expectant mothers with multiple pregnancies. Studies have also recommended tailored birth plans, with delivery at 36 weeks for monochorionic and 37 weeks for dichorionic multiple pregnancies to optimize maternal and neonatal outcomes [27].

Additionally, the study found that women with a history of hypertension had a significantly higher prevalence of stillbirth compared to those without hypertension. Hypertension is a well-established risk factor for adverse pregnancy outcomes. It compromises placental blood flow, reducing the oxygen and nutrient supply to the fetus, and increases the risk of placental abruption (a serious condition where the placenta prematurely detaches from the uterine wall). Hypertension also contributes to fetal growth restriction and can necessitate early delivery (preterm birth) to protect both the mother and baby, which further heightens the risk of complications. Similar studies have consistently reported these findings across various populations [28–30].

The study also found that women with history of miscarriage had higher prevalence of stillbirth that those without such history. The possible explanations to this could be that women who have experienced miscarriages may have underlying reproductive health problems, such as uterine abnormalities, hormonal imbalances, or conditions like polycystic ovary syndrome, which can contribute to pregnancy complications, including stillbirth

Furthermore, the study revealed that one-third of women of reproductive age in Tanzania are classified as either overweight or obese. In contrast, a previous study conducted in Dar es Salaam, the country's major city, reported a significantly higher prevalence of 50.4% [18]. This elevated rate in the urban setting can be attributed to the increased risk of obesity associated with urbanization.

It was also noted that the prevalence of stillbirth increases with rising BMI. Specifically, women who were overweight had a stillbirth prevalence of 6.2%, while those who were obese had a prevalence of 9.8%, compared to 4.2% among women with a normal BMI. Both pre-pregnancy overweight and obesity, as well as excessive weight gain during pregnancy, are significant determinants of increased risks for pregnancy loss, gestational diabetes, hypertensive disorders, labor complications, and maternal mortality [31].

The study also found a significant association between obesity and stillbirth, which remained evident even after adjusting for various factors such as maternal age, marital status, education level, household wealth, place of residence, distance to health facilities, and histories of multiple pregnancies, hypertension, and previous miscarriages. This finding is consistent with similar research conducted in Sweden [32]

While the study is comprehensive, its cross-sectional design limits the ability to establish causal relationships between BMI and stillbirth. However, we addressed this limitation by conducting a robust regression analysis and controlling for potential confounders. This methodological approach enhances the reliability of our findings and minimizes the impact of the design constraint.

In this study, a significant proportion of women reported experiencing at least one stillbirth. The findings also revealed a substantial prevalence of overweight and obesity among the participants. Women with obesity were found to be at a significantly higher risk of stillbirth compared to those with normal weight, even after accounting for other potential influencing factors. These results emphasize the critical link between maternal obesity and adverse pregnancy outcomes, underscoring the importance of addressing obesity in reproductive health strategies.

ANC	Antenatal Clinic
BMI	Body Mass Index
DHS	Demographic and Health Survey
MIS	Malaria Indicators Survey
NIMR	National Institute for Medical Research
TDHS-MIS	Tanzania Demographic and Health Survey and Malaria Indicators Survey
UNICEF	United Nations Children's Fund.
UN	United Nations
ZAMREC	Zanzibar Medical Ethics and Research Committee

Ethics approval and consent to participate

This study used secondary data without involving any human subjects. Hence, no formal ethical approval was required. However, the permission to use the data was obtained from the DHS program. The procedures for TDHS-MIS data collection were approved by the following organizations: Tanzania's National Institute for Medical Research (NIMR), the Zanzibar Medical Ethics and Research Committee (ZAMREC), the Institutional Review Board of ICF International, and the Centers for Disease Control and Prevention in Atlanta, USA. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.

Consent for publication

Not applicable

Availability of data and materials

The datasets used is available upon request from DHS-Measure

Competing interests

The authors declare that they have no competing interests

Funding

It was not a funded project, no specific funding to be declared

Authors' contributions

FVM led the conceptualization process, initiated the data analysis, and authored the introduction and discussion sections, while also conducting a critical review of the manuscript. AB was responsible for writing the methods section, performing the data analysis, and providing a thorough critical review of the manuscript. All authors actively participated in the review process and ultimately approved the final version of the manuscript.

Acknowledgements

The authors are deeply grateful to the administration of the DHS Programme for granting permission and providing access to the dataset for analysis.

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No competing interests reported.

Obesity Linked to Higher Risk of Stillbirth: Insights from the Tanzania Demographic and Health Survey

Status:

Version 1

Abstract

Figures

Background

Methods

Study design

Variables

Inclusion criteria

Data analysis

Results

Participants’ baseline characteristics

Maternal BMI and risk of stillbirth

Age and risk of stillbirths

Pregnancy history, hypertension, and stillbirths

Factors associated with the risk of stillbirth

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1