Beyond proximity: an observational study of stillbirth rates and emergency obstetric and newborn care accessibility in The Gambia.

INTRODUCTION: Stillbirths are disproportionately concentrated in sub-Saharan Africa, where geographical accessibility to basic/comprehensive emergency obstetric and newborn care (BEmONC and CEmONC) significantly influences maternal and perinatal outcomes. This study describes stillbirth rates within healthcare facilities in The Gambia and examines their distribution in relation to the geographical accessibility of these facilities. METHODS: We analysed 97 276 births recorded between 1 January 2013 and 31 December 2018, from 10 major public healthcare facilities in The Gambia. To standardise definitions, stillbirths were defined as fetal deaths with a birth weight of ≥500 g. Fresh stillbirths were reclassified as intrapartum, and macerated stillbirths were reclassified as antepartum. Linear regression with cubic splines was used to model trends, and AccessMod software estimated travel times to facilities. RESULTS: Among recorded births, 5.1% (4873) were stillbirths, with an overall stillbirth rate of 51.3 per 1000 births (95% CI: 27.5 to 93.6). Intrapartum stillbirths accounted for 53.8% (27.6 per 1000 births; 95% CI: 14.4 to 49.8). Fully functional CEmONC facilities reported the highest stillbirth rates, including the National Teaching Hospital (101.7 per 1000 births, 95% CI: 96.8 to 106.8). Approximately 42.8%, 58.9% and 68.3% of women aged 15-49 lived within a 10, 20 and 30 min travel time, respectively, to fully functional CEmONC facilities, where high stillbirth rates were concentrated. CONCLUSIONS: In The Gambia, intrapartum stillbirth rates remain alarmingly high, even in geographically accessible CEmONC facilities. Inadequate documentation of fetal heart rate on admission hampers accurate classification, complicating targeted interventions. Ensuring that EmONC-designated facilities-particularly those providing BEmONC services-are fully functional with essential equipment, trained staff and robust referral systems, while enhancing the timeliness and quality of obstetric care, is crucial to reducing stillbirth rates.