Background: Existing reviews of pre-eclampsia determinants have focused on clinical and genetic risk factors. Objective: To evaluate social determinants for pre-eclampsia prevention. Search strategy: Systematic searches were conducted on relevant electronic databases to 31 st July 2023. Selection criteria: Reviews and large cohort studies (≥1,000 participants), published within the last 10 years, reporting quantitative associations between social determinant exposures and pre-eclampsia outcomes. Data collection and analysis: Titles and abstracts and then relevant full-texts were reviewed by two reviewers, independently. Strength of association was evaluated as ‘definite’ (odds ratios [OR] or relative risk [RR] ≥3.00 or <0.33), ‘probable’ (OR or RR 1.50-2.99 or 0.33-0.67), ‘possible’ (OR or RR 1.10-1.49 or 0.68-0.89), or ‘unlikely’ (OR or RR 0.90 - 1.09). Quality of the evidence was high, moderate, low, or very-low, using GRADE. Main results: Twenty-six publications found 22 associations of pre-eclampsia with socioeconomic status, social support/exclusion, healthcare access, and occupational and physical environmental factors. One association (polygamy) was definite (low-quality evidence). Probable associations included: work stress and lack of antenatal care (high-quality evidence); prolonged occupational exposure to whole body vibrations or bending, elevated temperatures beyond seasonal norms, and UV-B radiation exposure (protective factor), all based on moderate-quality evidence; and Asian/Oceanian origins (protective, low-quality evidence). There were 11 possible associations, which did not include education. Conclusion: Our findings support recommendations to address climate change, strengthen occupational protection, and promote early ANC attendance. Social determinants may be indicative of upstream factors (e.g., obesity) that increase likelihood of clinical risk factors for pre-eclampsia incidence and severity.

Background: Sub-Saharan African (SSA) countries have high stillbirth rates compared to high-income countries, yet research on risk factors for stillbirth in SSA remain scant. Objectives: To identify the modifiable risk factors of stillbirths in SSA and investigate their strength of association using a systematic review. Search Strategy: EMBASE, MEDLINE, Global Health, and CINAHL Plus databases were searched for literature. Selection Criteria: Observational population- and facility-level studies exploring stillbirth risk factors, published between 2013-2019 were included. Data Collection and Analysis: Narrative synthesis of data was undertaken and the potential risk factors were classified into sub-groups. Main Results: Thirty-seven studies were included, encompassing 20,264 stillbirths. The risk factors were categorized as maternal antepartum (0-4 antenatal care visits, multiple gestations, hypertension, birth interval >3 years, history of perinatal death); socioeconomic factors (maternal lower wealth index and basic education, advanced maternal age, grand multiparity (≥5)); intrapartum (direct obstetric complication, non-vaginal delivery); fetal (low birthweight and gestational age <37weeks) and health systems (poor ANC quality, emergency referrals, ill-equipped facility). The proportion of unexplained stillbirths remained very high. No association was found between stillbirths and HIV, BMI, diabetes, and distance from the facility. Conclusion: The overall quality of evidence was low as many studies were facility-based and did not adjust for confounders. This review identified preventable risk factors for stillbirth. Focused programmatic strategies should be developed to improve antenatal care, emergency obstetric care, maternal perinatal education, referral and outreach systems, and birth attendant training. More population-based high-quality research is needed. Funding: Not externally funded

Objective To quantify parents’ experiences of respectful care around stillbirth globally. Design Multi-country, online, cross-sectional survey. Setting and Population Self-identified bereaved parents (n=3769) of stillborn babies from 44 high- and middle-income countries. Methods Parents’ perspectives of 7 aspects of care quality, factors associated with respectful care, and 7 bereavement care practices were compared across geographical regions using descriptive statistics. Respectful care was compared between country income groups using multivariable logistic regression. Main Outcome Measures Self-reported experience of care around the time of stillbirth Results A quarter (25.4%) of 3769 respondents reported disrespectful care after stillbirth and 23.5% reported disrespectful care of their baby. Gestation <30 weeks, and primiparity were associated with disrespect. Reported respectful care was lower in middle-income countries (MICs) than in high-income countries (HICs) (aOR=0.35, 95%CI (0.29-0.42), p <0.01). In many countries, aspects of care quality need improvement, such as ensuring families have enough time with providers. Participating respondents from Latin America and Southern Europe reported lower satisfaction across all aspects of care quality compared to Northern Europe. Unmet need for memory-making activities in MICs is high. Conclusions Despite improvements, many parents still experience disrespectful care around stillbirth. The gap between parents’ access to memory-making activities in MICs and HICs needs urgent attention. Tweetable abstract A quarter of parents of stillborn babies experience disrespectful care. There is global unmet need for memory-making activities