This study reports a comprehensive analysis of the burden of, and risk factors for, stillbirth in a cohort of women presenting for delivery at two regional referral hospitals in Uganda. It also emphasizes the impact that stillbirths have on post-discharge trajectories. Among women experiencing a stillbirth, nearly 1 in 10 women required admission during the first 6 weeks following delivery. These results emphasize the urgent need for interventions that not only reduce the high rates of stillbirths but also improve postpartum care for women who experience stillbirths.

The present analysis affirms prior research that has shown that social and geographic vulnerability, alongside clinical risk factors, are important features that are associated with stillbirths (1). Lower socioeconomic index scores, delayed access to health facilities due to terrain features (lakes, floods, poor roads, etc.), and timely access to transportation were all important risk factors for stillbirth (13). A history of previous child death was the strongest predictor of stillbirth in the current cohort. Women who had such a history had over seven times the odds of stillbirth compared to those with no prior history of a loss. These results reflect the multifactorial nature of stillbirths and reinforce the call for strengthening the health system to tackle modifiable factors and improve outcomes.

In this analysis, we found that just over half of stillbirths were classified as fresh, suggesting fetal demise during labor or delivery. This is consistent with prior research in resource-limited settings (14) and points to critical gaps in intrapartum care, particularly fetal monitoring and management of labor complications (15,16). In contrast to the fresh stillbirths, the macerated stillbirths suggest antepartum causes, and our results point to these being tied to socioeconomic and clinical vulnerabilities, demonstrating the clear need for the strengthening of antenatal care services. Overall, stillbirths in general were associated with meconium-stained amniotic fluid, preterm delivery, and transportation delays, suggesting delays in recognition and response to fetal distress. These results largely align with studies in sub-Saharan Africa that link intrapartum stillbirths to inadequate labor monitoring, obstructed labor, and limited access to emergency obstetric care (17).

This analysis also identifies a range of maternal, environmental, and clinical factors that significantly influence in-hospital neonatal mortality, many of which reflect systemic barriers to accessing timely and quality care. Environmental delays, especially those caused by adverse weather conditions and difficult terrain, are key obstacles to reaching a health facility (18,19). Clinically, preterm birth remains one of the strongest predictors of neonatal death, consistent with known risks such as respiratory distress, immaturity, and increased infection vulnerability among premature babies (20,21). A history of prior child death also raises the risk of neonatal mortality, indicating persistent maternal or fetal risk factors like chronic illness or limited antenatal care that can affect subsequent pregnancies (22,23). From a health system view, referrals from lower-level facilities are linked to poorer neonatal outcomes, reflecting delays in triage, transportation, and emergency coordination. Given that caesareans are often life-saving, their association with neonatal mortality here likely indicates emergency cases and complications related to the procedure (24,25).

Postpartum readmission was significantly more common among women who experienced stillbirth compared to those with live births, highlighting a potential area for targeted postpartum support. Women readmitted after stillbirth were more likely to report antenatal morbidity and socioeconomic hardship, suggesting that the cumulative burden of medical and social vulnerabilities may increase the risk of complications following discharge. These findings are consistent with population-based studies that have demonstrated higher rates of postpartum readmission among women with stillbirth, largely driven by unresolved physical complications, such as infection and hemorrhage, as well as psychological distress (26). Moreover, prior research has emphasized that bereaved mothers often experience limited social support and face barriers to accessing appropriate postpartum follow-up care, compounding their risk of readmission (27). These results underscore the importance of integrating mental health services and individualized medical follow-up into the postpartum care pathway for women who experience stillbirth, particularly those with underlying antenatal complications or socioeconomic disadvantage.

This study has several limitations. First, the observational design restricts our ability to determine causality between the identified risk factors and stillbirth or postpartum readmission. Second, data were collected from two major regional referral hospitals that serve both urban and rural populations. Although we believe these hospitals to be broadly representative of the Ugandan population, the results may lack generalizability to lower-tier health facilities or private healthcare facilities where barriers to care and outcomes may differ. Lastly, self-reported measures of socioeconomic status and care-seeking behavior can be influenced by recall and social desirability biases, especially among women who have experienced stillbirth, potentially affecting the accuracy of these responses.

In conclusion, this study reports important insights into the multifactorial contributors to stillbirth and postpartum readmission in a low-resource setting. Our findings underscore the critical role of both clinical and social determinants, including previous child loss, preterm delivery, antenatal morbidity, and care-seeking delays in shaping maternal and perinatal outcomes. The distinct patterns observed between intrapartum and antepartum stillbirths highlight the need for context-specific strategies to strengthen intrapartum care and address upstream social vulnerabilities. Moreover, the significantly higher postpartum readmission rates among women who experienced stillbirth point to unmet health needs and potential gaps in post-discharge care. These results call for integrated interventions that prioritize early risk identification, improve access to emergency obstetric care, and extend support beyond hospital discharge, especially for bereaved mothers. Investing in such targeted efforts will be essential to reducing preventable stillbirths and improving long-term maternal health outcomes. These findings also collectively emphasize the intricate factors leading to neonatal mortality and the pressing need to improve maternal and newborn care across the entire continuum, from antenatal monitoring to facility-based delivery and postnatal care.