Elucidating Delays in Illness Recognition, Healthcare Seeking, and Healthcare Provision for Stillbirths and Neonatal Deaths in Seven Low- and Middle-Income Countries

An estimated 1.9 million stillbirths and 2.3 million neonatal deaths occurred globally in 2023, disproportionately clustered in sub-Saharan Africa and South Asia. We aimed to determine the frequency of delays in illness recognition, healthcare seeking, and healthcare receipt among cases of stillbirth neonatal death, to characterize the most common delays, and to describe the frequency of antenatal care visits preceding stillbirths and neonatal deaths. We conducted a descriptive analysis of deaths enrolled during 2016-2023 in the Child Health and Mortality Prevention Surveillance (CHAMPS) network, which prospectively studies stillbirths and child deaths in seven low- and middle-income countries. Delays in 1) illness recognition in the home/decision to seek care, 2) transportation to healthcare facilities, and 3) the provision of clinical care (e.g., timely administration of medications, etc.) in healthcare facilities were categorized according to the "Three Delays-in-Healthcare” framework. We included 7,079 deaths (3,424 stillbirths and 3,655 neonatal deaths). Among included stillbirths, 53.6% were male and the median maternal gestational age was 36 weeks (interquartile range [IQR] 32, 38 weeks). Among included neonatal deaths, 57.3% were male and the median maternal gestational age at delivery was 34 weeks (IQR 30, 38 weeks). Overall, 96.8% (n=3,313) of stillbirths and 97.7% (n=3,571) of neonatal deaths had ≥1 delay identified, the most common being those related to the delivery of high-quality clinical care in health facilities, despite 84.9% of stillbirths and 82.9% of neonatal deaths occurring in healthcare facilities. Nearly half of mothers of stillbirths (47%) and 41% of mothers of neonates who died had ≤3 antenatal care visits recorded. Despite high facility delivery rates, healthcare provision delays were the most predominant, suggesting that strengthening facility-based clinical care quality, rather than improving facility access, may be the most impactful intervention for reducing perinatal mortality in these settings.