Australian and New Zealand Journal of Obstetrics and Gynaecology 2015; 55: 331–336 DOI: 10.1111/ajo.

12337

Original Article

A retrospective review of stillbirths at the national hospital in Timor-Leste

Alexa WILKINS,1 Jaya EARNEST,2 Elizabeth Anne MCCARTHY3 and Alexis SHUB3
1
International Health Programme, School of Nursing and Midwifery, Curtin University, 2Faculty of Health Sciences, International
Health Programme, School of Nursing and Midwifery, Curtin University, Perth, Western Australia, and 3Melbourne University Medical
School, University of Melbourne, Melbourne, Victoria, Australia

Background: Timor-Leste has high maternal and infant mortality rates. Estimates of stillbirths are unreliable and limited
by poor collection of vital health statistics. Lack of accurate data impedes the development of interventions to address local
determinants of stillbirth.
Aims: This study aimed to identify the rate, timing and causes of stillbirths at National Hospital Guido Valadares in Dili,
Timor-Leste, between November 2009 and December 2010, during which data were available.
Methods: Hospital birth registry and maternal records were retrospectively reviewed to identify stillbirths during the study
period. The simplified Cause of Death and Associated Conditions system was utilised to classify stillbirths.
Results: One hundred and fifty-three stillbirths were identified, producing a stillbirth rate of 29 per 1000 births. Of
stillbirths with known timing, 70 (66.7%) occurred antepartum and 35 (33.3%) intrapartum. Cause of death could not be
ascertained in 62.7% of cases due to poor or missing records. Where identified, the three most commonly classified causes
of death were intrapartum fetal asphyxia, maternal infection and maternal hypertensive disorder.
Conclusion: This study highlights the need for standardised recording and coding of perinatal deaths at HNGV. The
high proportion of antenatal death transfers from community health centres demonstrates the need for community and
hospital staff training to improve the quality of antenatal and intrapartum obstetric care. A prospective study of
stillbirths is recommended to obtain reliable data on the determinants of stillbirths in Timor-Leste. These data would
inform evidence-based interventions for the improvement of maternity and obstetric care in community and hospital
settings.
Key words: cause of death, East Timor, low-income countries, perinatal mortality, stillbirth.

Introduction Worldwide, stillbirths are an underreported health issue,

In 1999, the Democratic Republic of Timor-Leste
declared independence from over 400 years of Portuguese
colonisation and 25 years of Indonesian occupation; this
was followed by violence and destruction that destroyed
the country’s health infrastructure and resources.1 Timor-
Leste was recognised as a sovereign state in 2002;
however, redevelopment has been slow.1,2 Timor-Leste
remains one of the poorest countries in the Asia-Pacific
region, and the World Health Organization (WHO)
estimates maternal mortality rates, at 300 per 100,000 live
births, and the neonatal mortality rate, at 24 per 1000 live
births.3
Correspondence: Ms Alexa Wilkins, International Health
Programme, School of Nursing and Midwifery, Faculty of
Health Sciences, Curtin University of Technology, GPO Box
U1987, Perth, Western Australia, 6845.
Email: lexwilkins83@gmail.com
Received 24 November 2014; accepted 2 March 2015.
yet an estimated 2.65 million occur annually and account
for almost half of all perinatal deaths.4 The vast majority
occur in resource-poor settings,5 yet only recently has the
importance of counting and analysing deaths been
recognised in developing countries.6 In Timor-Leste, the
estimated stillbirth rate is 14 per 1000 total births,3 but this
figure is unreliable since neither facility nor community
death data are reported systematically and accurately, and
limited progress has been made towards a vital health
statistics reporting system.2 In 2010, only 50% of births in
Timor-Leste were registered,7 with the majority of women
giving birth at home (78%) and only a small proportion
delivered by a skilled birth attendant (30%).2 The lack of
data impacts identification of stillbirth rate, timing and
causes, and impedes the development of interventions to
address local determinants of stillbirth.5,8–11
Hospital-based perinatal deaths in Timor-Leste are not
reported by diagnosis, and there is no standardised coding
system in use.2 The aim of this study was to identify the
rate of stillbirths and classify possible causes of death
(COD) through a retrospective review of medical records
at the national hospital in the capital city, Dili (HNGV).

© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 331
The Australian and
New Zealand Journal
of Obstetrics and
Gynaecology
A. Wilkins et al.
Materials and Methods
A retrospective study of stillbirths delivered between
November 2009 and December 2010 at HNGV was
undertaken. This time period was selected because
maternal records were available at HNGV for this period
only, as for lengthy periods before and after this time, the
medical records department was not operational. The
majority of the records from the time period selected were
stored in a cupboard in the maternity department without
any organisation either by date of attendance or patient
name; however, some records were missing. The majority
of records were labelled only with the woman’s name and
suburb. Hospital numbers and date of birth were not used.
Ethics approval was obtained from the Human Research
Ethics Committee at Curtin University. Ethics approval
was not required from HNGV as the study comprised
audit only.
HNGV is the main referral hospital for residents in five
of Timor-Leste’s 13 districts, and its catchment area
accounts for 46% of Timor-Leste’s population.12,13 There
are approximately 4500 births per year at HNGV, and this
constitutes the majority of hospital births in Timor-Leste;12
routinely collected information on birth outcomes is limited
to numbers of births, mode of delivery, birthweight, gender
and singleton–multiple birth status, and there is sparse and
inconsistent recording of obstetric complications. There is
no ability to perform post-mortems or other recommended
investigations8 to determine the cause of death in stillbirth,
except a full blood count. As part of routine care,
birthweight was measured using analog scales and
gestation was determined using the woman’s recall of her
last menstrual period.
The HNGV birth registry was manually searched for
stillbirths and identified by Apgar scores of 0 at 1 and 5 min
of age. Mothers’ name, age, residence and date of delivery
for each case were recorded. Maternal records from this
period were manually searched using this information to
identify the matching inpatient record and document the
woman’s referral, obstetric and delivery details.
Data were collected and entered directly into a
spreadsheet, adapted from the WHO Southeast Asia
Regional Office stillbirth record form (Appendix S1),
which was used to document the details of the mother’s
referral to HNGV, any preceding obstetric complications
and the stillbirth. The WHO International Classification of
Diseases definition of stillbirth (death of a fetus weighing
≥500 g or, if birthweight was unavailable, gestational age
of ≥22 weeks) was used as inclusion criteria in the study.14
Data from the birth registry and maternal records for
stillbirths were cross-checked for inconsistencies or
omissions.
The simplified Cause of Death and Associated
Conditions (CODAC) classification system, developed
specifically for use in low-income settings, was used to
classify COD incorporating all available obstetric details
documented in the birth registry and maternal records by
authors AS and AW.15 We added level two classifications
332 © 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
to the simplified system from the complete CODAC
classification where a clear cause of death was determined,
but not described in the simplified classification, for
example cord prolapse. Evaluation of the full CODAC
system has demonstrated its consistency in identifying
underlying COD and capturing associated narrative
features.15,16
Cause of Death and Associated Conditions rules states
that intrapartum deaths where no cause was found should
be coded as ‘29 intrapartum unknown’. A decision was
made to code these as ‘81 unknown’, because no
investigations or clinical history were available in these
cases, so COD was unknown because it had never been
sought, not because it was truly unknown. In cases where
we were able to document a true intrapartum death, as
opposed to a death diagnosed intrapartum but where
actual timing of death was unknown, we have classified
these as ‘29 intrapartum unknown’, as recommended.
We assessed quality of care based on our knowledge of
the available resources and staff training from extensive
time spent as an obstetrician in the hospital. A formal
assessment tool was not used.
All statistical analysis was performed using IBM SPSS
21 Statistics (IBM Corp, Armonk, NY, New York State,
USA). A chi-square test of independence was performed
in SPSS to examine the relationship between timing of
stillbirth (antepartum or intrapartum) and variables,
including residence, parity, singleton/twin status, maternal
age and mode of delivery.
Results
Among the 5304 births at HNGV between November
2009 and December 2010,12 153 stillbirths were identified
in the HNGV birth registry and maternal records (Fig. 1).
This produces a stillbirth rate of 29 per 1000 births.
Fifty-two of the 153 stillbirths (34%) had no maternal or
obstetric details documented and were therefore included in
the analysis using information only from the birth registry.
Of the 153 stillbirths, 89 (58.2%) were from singleton
pregnancies, 12 (7.8%) were from twin pregnancies in
which both twins died, 10 (6.5%) were from twin
pregnancies in which one twin died and 42 (27.5%) had
unknown singleton–multiple pregnancy status. In total, 153
stillbirths were delivered by 147 women. The demographic
characteristics of the women are shown in Table 1.
Characteristics of the 153 stillbirths are shown in Table 2.
The gestational age was determinable in 80 of the 153 cases,
ranging from 22 to 42 weeks, with a mean of 32.4 weeks’
gestation.
Seventy (45.7%) deaths occurred before labour, 35
(22.9%) in labour and 48 (31.4%) had an unknown time
of diagnosis. Among the 70 antenatal deaths, 61 were
diagnosed before labour and nine were diagnosed during
labour but were macerated, implying an antenatal timing
of death. Of these antenatal deaths, in 19 cases, the
mother had detected no fetal movement from between one
day to three weeks prior to presentation and there was no
 Hospital stillbirths in Dili, Timor-Leste

Hospital birth registry manually

searched for stillbirth cases

3 Excluded
(weight <500
152 Recorded stillbirths (Apgar 0/0)
grams and
retrieved from birth registry
gestation <22
weeks)
149 Stillbirths retrieved
from birth registry

2 Excluded 103 Hospital maternal 46 Stillbirth 6 Stillbirth cases

(Apgar 1/0 in
records retrieved to match cases with no added
maternal record)
stillbirth cases matching (identified in
hospital maternal record
maternal but
101 Stillbirth cases with records undocumented
matching identified in birth registry)
maternal record retrieved

153 Stillbirth cases included for

analysis

Figure 1 Flowchart of inclusion and exclusion criteria for retrospective review of stillbirth.

Table 1 Demographic characteristics of women with a stillborn No significant relationships were found between timing
baby (n = 147) of stillbirth and demographic and obstetric variables (data
not shown).
Percentage Ninety-six stillbirth cases (62.7%) were classified as
Characteristic Category n of women ‘Unknown’ due to missing records or poor documentation
Maternal age <20 8 5.4 of obstetric complications. Among the stillbirth cases
(years) 20–24 45 30.6 where COD were identified (n = 57), the most frequent
25–34 70 47.6 COD were attributed to intrapartum causes (n = 17) and
≥35 24 16.4 hypertension (n = 12; Table 3).
Residence Dili 88 59.9 Review of the maternal records identified a number of
Other district 51 34.7 examples of care at a lower standard than would be
Unknown 8 5.4 expected for the available facilities. The most common
Parity 0 49 33.3 examples related to birth attendants’ failure to monitor the
1 28 19.0 fetal heart or respond to fetal heart rate abnormalities in
2–5 48 32.7 the active stage of labour, incorrect diagnoses from
≥6 22 15.0 ultrasound (eg singleton pregnancy diagnosed as twins on
ultrasound), failure to record maternal temperature or
blood pressure over periods of more than 24 h in women
record in the remaining cases. Among the antenatal with hypertension or ruptured membranes, and otherwise
deaths, 37 (52.9%) women were transferred into HNGV poorly recorded documentation on the partograph.
from another clinic, 28 (40%) presented to HNGV and in
5 (7.1%) cases, it was unknown whether the woman was
Discussion
transferred or presented to the hospital.
Thirty-five stillbirth cases were diagnosed in labour, and The present retrospective study identified a stillbirth rate
of these, 11 were confirmed intrapartum deaths, one was of 29 per 1000 at HNGV, twofold higher than the most
termination of a presumed nonviable pregnancy, and in recent WHO estimate for Timor-Leste (14 per 1000
23, the exact timing of death was unknown. The majority births) and higher than the average for Southeast Asia (22
of women among whom the timing of death could not be per 1000 births).3 However, the WHO estimates are
determined presented in advanced labour, and there was based on a stillbirth definition (the death of a fetus
no documentation as to whether the infant was fresh or weighing ≥1000 g or ≥28 weeks of gestation) that varies
macerated. from that used in the study.3 Using the narrower WHO

© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists 333
A. Wilkins et al.

Table 2 Characteristics of stillbirth cases (n = 153) Table 3 Simplified Cause of Death and Associated Conditions
(CODAC) Classification of stillbirth cases15 (n = 59)
Percentage
Characteristic Category n of stillbirth cases CODAC Cause of death Cause of death
number (level I) (level II) n
Singleton–multiple Singleton 89 58.2
birth status Twin 22 14.4 05/06† Infection – 9
Unknown status 42 27.4 20 Intrapartum – other Ruptured uterus 3
Gender of baby Male 83 54.2 23 Intrapartum Malpresentation 1
Female 69 45.1 25 Intrapartum Prolonged/obstructed 3
Unknown gender 1 0.7 or incomplete labour
Gestation at 22–26 17 11.1 29 Intrapartum Unknown (fetal 10
birth (weeks) 27–31 15 9.8 respiratory failure/
32–36 23 15.0 asphyxia)
≥37 25 16.3 Cord prolapse 3
Unknown gestation 59 38.6 30 Congenital – 3
Improbable 14 9.2 anomaly‡
gestational age 31 Congenital Central nervous system 5
Mode of delivery Vaginal cephalic 74 48.4 anomaly
Caesarean 21 13.7 60 Placenta Praevia 5
Vaginal breech 28 18.3 63 Placenta Abruption 2
Unknown delivery 30 19.6 71 Maternal Hypertensive disorder 12
mode 94 Termination For maternal condition 1
Birthweight (g) <500 1† 0.7
†Diagnosis of infection was based on clinical diagnosis of
500–1499 52 34.0
chorioamnionitis. No microbiology was performed, so it was not
1500–2499 40 26.1
possible to determine whether infection was GBS or non GBS.
2500–3499 35 22.9
‡One case described only as ‘abnormal baby’, one ‘abnormal feet
≥3500 22 14.4
and hands and cleft lip’, one ‘skull and polyhydramnios’.
Unknown 3 2.0
birthweight
Taking into account the proportion of cases in which
†This case was included despite birthweight less than 500 g
timing of death was known (n = 103), the proportion of
because it was one of a set of twins in which the larger twin
weighed 1200 g.
intrapartum stillbirth in the study was 33.9%; this is
comparable to other population-level studies in low-income
countries.17–20 Most stillbirths occurred in the antenatal
definition results in a stillbirth rate of 24 per 1000 at period, emphasising the need for improved education and
HNGV in the study period, which is still 1.5 times higher awareness among pregnant women and antenatal care
than the WHO estimate for Timor-Leste. This rate is also providers about fetal movements and other danger signs in
higher than previously estimated because of the large the antenatal period. The high parity observed in many
number of women referred to HNGV because of known cases (15% of women with parity ≥6) is consistent with the
stillbirth. high rate of unmet need for family planning in Timor-Leste
More than 60% of all cases weighed less than 2500 g, (31.5%), among the highest in the world.21
and 73% of cases with recorded gestation were <37 There are a number of identified demand gaps in
completed weeks. Gestation was estimated only using the seeking obstetric care at a health facility in Timor-Leste.
woman’s recall of her last menstrual period at the time she Knowledge of danger signs in pregnancy was low among
was seen at the hospital. This is a limitation as it has a women surveyed in the Timor-Leste Demographic Health
high degree of inaccuracy especially in a country where Survey 2009–2010,2 and late recognition of danger signs
illiteracy rates are high.2 In 14 cases, gestational ages were by Timorese traditional birth attendants has been
considered implausible due to large discrepancy between identified as delaying access to care at health facilities.22
the birthweight and the accepted gestational age, and in This was notable in the present study with 19 cases of
these cases, only birthweight was used. Birthweight was women reporting no fetal movement for significant periods
recorded using analog scales, and significant terminal digit prior to presentation.
preference was shown with the majority of weights Other studies in Timor-Leste have outlined barriers to
recorded at intervals of 100 g. Although birthweight and accessing facility-based health care, including mistrust,
gestation data are approximate, these proportions still fear of judgment by health staff, cultural beliefs and family
indicate that a high number of cases were preterm and/or traditions that encourage birthing at home, and
growth-restricted. There are limited published comparative geographical distances and frequent flooding that restricts
data from similar settings, because many babies are not travel to facilities.2,22–25 These all pose challenges to
weighed at birth, and similar limitations exist around increasing the number of facility-based deliveries in
women’s knowledge of gestational age. Timor-Leste.

334 © 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists

There are, however, a number of supply-side gaps at
HNGV, highlighted by the intrapartum deaths that
constituted almost one-third of all stillbirths. The events
relating to poor care were similar to those identified in other
reviews of stillbirth in low-income settings.26–29 Fifty-three
(34.6%) babies weighed 1500 g or less; at this weight,
survival is low and invasive intervention such as caesarean
section would not be appropriate for fetal well-being.
Maternal records were missing in 46 stillbirth cases, and
poor documentation resulted in 62.7% of all cases
classified as Unknown COD. This highlights a critical gap
in adequate record keeping and patient documentation at
HNGV. This poor documentation may be attributed to a
lack of awareness and understanding among staff of the
importance of recording patients’ clinical details, a lack of
training in data recording, combined with limited
resources and rudimentary means of storing patient data.
Limitations
The limitations of the study are intrinsic to its
retrospective design. The extremely poor documentation
of stillbirths at HNGV, the high proportion of missing
data and the lack of national vital statistics prevented
exploration and meaningful statistical analysis of
determinants and COD.
Our data provide only an approximation of the stillbirth
rate at the national hospital given the inaccuracies inherent
in the data collection; however, we believe this study is the
first widely accessible audit of stillbirths in Timor-Leste
and provides descriptive data on stillbirths at HNGV. The
stillbirth rate could also be an underestimation given the
data collection process identified an additional six cases in
the maternal records that had not been recorded in the
birth registry.
The accuracy of COD and associated conditions was
constrained by missing data and lack of documentation on
obstetric complications, limiting the ability to draw
conclusions on the factors that contributed to stillbirth.
Important information may also have been lost when
assigning a single COD as this does not always account
for the complex biosocial context within which the death
occurs.16, 26
As a hospital-based study, the large proportion of
homebirths in Timor-Leste was not captured, and
therefore, the results are not nationally representative and
cannot be generalised outside HNGV.
Recommendations
The descriptive data from the study and the identified
COD highlight much-needed improvements in the
provision of appropriate standards of obstetric care in
Timor-Leste and at HNGV. This includes interventions in
line with WHO recommendations, appropriate triage to
support rapid intervention, and training for doctors and
midwifery staff in practical skills to reduce intrapartum
complications, technical skills to provide continuous care
© 2015 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
Hospital stillbirths in Dili, Timor-Leste
during labour, and obstetric drills and simulations to
improve emergency obstetric care.11,25–29
The study emphasised the antenatal period as an
important time to implement interventions to prevent
stillbirths. This includes education and awareness raising
among pregnant women and community antenatal care
providers on danger signs in the antenatal period.
Strategies to increase access to healthcare facilities for
childbirth among the Timorese population are also
important and could include greater investment in
outreach clinics, health promotion campaigns and cultural
awareness training for hospital staff. One such program
already demonstrating success in Timor-Leste is Liga Inan
(‘Mobile Mums’), which uses mobile phones to connect
pregnant women and midwives, whereby women receive
weekly text messages with health information and
reminders to attend antenatal care appointments.30
Standardised recording and auditing of stillbirth data at
HNGV and other hospitals in Timor-Leste would ensure
accurate data are collected, local causes and determinants
of stillbirth identified, and evidence-based programmatic
and clinical responses developed.6, 9, 15, 25, 31
The use of verbal autopsy in low-resource contexts has
been demonstrated as an effective tool for capturing
timing and cause of stillbirth information and could be
employed in Timor-Leste to document stillbirth data from
both community and healthcare facility settings.17
A prospective study is the most effective strategy to
identify associated factors and causes of stillbirth; such a
study is underway at HNGV and has been accompanied
by training for hospital staff in the recording and coding
of stillbirths and other perinatal deaths. Results from a
prospective study can be used to inform priority setting,
focussed planning and evaluation of prevention programs
and investment in interventions to improve the quality of
maternity and obstetric care at HNGV.6,32
Conclusion
The present study contributes to the widely overlooked
issue of stillbirths in low-income, resource-poor settings. It
highlights the critical importance of systematic collection
of vital statistics in Timor-Leste to inform interventions
aimed at improving maternal and infant health outcomes.
Standardised recording, coding and auditing of stillbirths,
training for nursing and midwifery staff to improve the
quality of obstetric care and labour monitoring, and
increased community awareness of danger signs in the
antenatal period may contribute to reductions in perinatal
mortality in Timor-Leste and other low-resource settings.
Acknowledgements
The authors wish to thank the staff at National Hospital
Guido Valadares for facilitating access to the birth registry
and maternal record data for the purposes of this study,
and the Royal Australasian College of Surgeons (RACS)
Australia Timor-Leste Program of Assistance for
335
A. Wilkins et al.
Secondary Services (ATLASS) staff, who provided
ongoing support to undertake the study. Thanks are given
to Dr Ingrid Bucens who shared data from her earlier
study at HNGV that supported the analysis in this study.
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Supporting Information
Additional Supporting Information may be found in the
online version of this article:
Appendix S1. WHO Southeast Asia Regional Office
stillbirth record form, adapted for Timor-Leste.