Fetal and early neonatal outcomes among facility-based maternal deaths in Luapula Province, Zambia (2019-2025): a retrospective cohort study
This retrospective cohort study of 233 facility-based maternal deaths in Luapula Province, Zambia (2019–2025), reveals that one in four fetuses died alongside their mother—primarily as fresh stillbirths suggesting delays in care during labor—while highlighting critical gaps in surveillance that prevent accurate tracking of neonatal outcomes following maternal death.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer
When a mother dies during pregnancy or childbirth, her baby often dies too. This is not a coincidence of bad luck, but a shared tragedy rooted in the same medical emergencies that threaten both lives. In many parts of the world, health systems track the death of a mother and the death of a baby as two separate events, recorded in different ledgers. This separation means that when a mother passes away, the fate of her infant frequently slips out of view, leaving a gap in our understanding of how to save lives. The question of what happens to the baby in these moments is critical, because the conditions that kill mothers—such as severe bleeding, high blood pressure, or infections—are often the very same conditions that kill their newborns. Understanding this link is essential for building health systems that can protect both lives simultaneously, rather than treating them as unrelated problems.
In the Luapula Province of Zambia, a region defined by its unique geography of islands and swamp channels, researchers set out to close this gap. They looked back at records from 2019 to 2025 to see what happened to the babies of women who died in health facilities. The province presents a challenging environment for care; some communities are accessible only by boat, meaning that time is lost crossing open water to reach a hospital. The researchers gathered data on every recorded maternal death in the province's health system, a total of 233 cases, and traced the outcome for each infant. They wanted to know if the baby was born alive or stillborn, and if born alive, whether the baby survived the first week of life. They also examined whether the location of the death—on an island or the mainland—or the reason for the mother's death influenced the baby's survival.
The study revealed a stark reality: one in four babies died alongside their mothers. Among the cases where the outcome could be clearly determined, 54 out of 211 babies were stillborn. The researchers found that most of these stillbirths were "fresh," meaning the baby died during labor or shortly before arriving at the hospital, rather than days earlier. This pattern suggests that the critical failure often happens after the mother has reached a medical facility, pointing to delays in receiving the right care at the right time. The cause of the mother's death mattered significantly for the baby's fate. When a mother died from high blood pressure disorders or malaria, the baby was most likely to die as well, with a stillbirth rate of one in three. In contrast, when the mother died from severe bleeding, the baby's chance of survival was slightly better, though still far from safe.
Surprisingly, the study found that the number of times a mother visited a doctor before labor did not predict whether her baby would survive. Women who had seen a doctor fewer than four times had the same rate of baby loss as those who had seen a doctor four or more times. This suggests that simply having contact with the health system is not enough; the quality of care during the actual emergency is what determines the outcome. The researchers also looked at whether living on an island made a difference. While island communities face significant barriers to reaching care, the study did not find a statistical difference in baby survival between island and mainland mothers. However, the researchers caution that this does not mean island mothers are safe. The number of island cases in the records was very small, and many women who died on islands or while traveling by boat were never recorded in the facility system at all. The lack of data likely hides the true danger these women face.
Perhaps the most troubling finding was the inability to track what happened to the babies who were born alive. The health records were so incomplete that the researchers could only find formal follow-up information for a tiny fraction of the surviving infants. They estimated that about 8 percent of the live-born babies died within the first week, but they acknowledged this number is almost certainly too low because the system stops watching the baby once the mother dies. A separate register of baby deaths in the province showed that many newborns die from lack of oxygen or being born too early, conditions that require immediate, skilled care. The fact that the system for tracking mother deaths and the system for tracking baby deaths do not share a common way to link the two records means that the full tragedy of these events remains invisible.
The researchers concluded that to save more lives, health systems must stop treating the mother and the baby as separate cases. Every review of a mother's death should include a clear record of what happened to her baby, and the two systems should be linked so that no infant is lost to the records. The high rate of fresh stillbirths indicates that even when a mother reaches a hospital, the care she receives may be too slow or insufficient to save her child. Improving the speed of decision-making, ensuring blood is available, and strengthening the ability to resuscitate newborns are the most urgent steps needed. In a place where the journey to care is already long and difficult, the final moments of labor must be managed with a precision that saves both lives, ensuring that the death of one does not automatically mean the death of the other.
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