Unclean Cooking Fuel Use and Stillbirth in Ghana: Evidence from the 2022 DHS

Kirstin P West^1,2,3Kristin K. Sznajder^2,3Grace Hwang²Hannah E. Sauve⁴Kedir Teji Roba^2,5,6Leonard BAATIEMA⁷Ernest Kenu⁷Charles L. Noora⁷Abraham Tamirat Gizaw⁸Abebayehu N. Yilma^2,3*

• ¹University of Washington, Seattle, United States
• ²Penn State College of Medicine, Hershey, United States
• ³Penn State Institute of Energy and the Environment, University Park, PA, United States
• ⁴Boston University, Boston, United States
• ⁵The Pennsylvania State University College of Health and Human Development, University Park, United States
• ⁶Haramaya University College of Health and Medical Sciences, Dire Dawa, Ethiopia
• ⁷University of Ghana School of Public Health, Accra, Ghana
• ⁸Jimma University Institute of Health, Jimma, Ethiopia

Introduction: Stillbirth remains a major public health issue in low-and middle-income countries (LMICs). Ghana's 2021 stillbirth rate (21.4 per 1,000 births) exceeds the United Nations Sustainable Development Goal (SDG) target of 12 per 1,000 births by 2030. Unclean household cooking fuels have been associated with adverse pregnancy outcomes, including stillbirth. In Ghana, women conduct about 64% of household cooking, often in poorly ventilated settings with particulate levels above World Health Organization (WHO) guidelines. We assessed the association between household cooking fuel type and stillbirth among Ghanaian women. Methods: We conducted a cross-sectional analysis using data from the 2022 Ghana Demographic and Health Survey. The sample included 10,654 women aged 15–49 years with ≥1 recorded pregnancy. The primary exposure was household cooking fuel (clean vs. unclean per WHO guidelines). Outcomes were (1) stillbirth, defined as fetal loss at ≥7 months' gestation, and (2) stillbirth rate per 1,000 total births. Survey-weighted bivariate screening (p<0.05) identified candidate covariates for inclusion in multivariable, survey-weighted logistic regression models. Adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were reported. Given the cross-sectional design, estimates reflect associations, not causation. Results: The overall stillbirth rate was 15.85 per 1,000 births. Unclean cooking fuel use was associated with 44% higher odds of stillbirth (AOR: 1.44; 95% CI: 1.05–1.99; p=0.0258). Other factors associated with higher odds were age ≥30 years (AOR: 2.17; 95% CI: 1.59–2.95; p<0.001), moderate-to-poor health (AOR: 1.78; 95% CI: 1.39–2.28; p<0.001), and alcohol consumption (AOR: 1.43; 95% CI: 1.06–1.93; p=0.0195). Discussion: In this nationally representative sample, unclean cooking fuel use was associated with increased odds of stillbirth. Expanding access to clean fuels and leveraging antenatal care services for culturally responsive clean-energy counseling may help reduce stillbirth risk. Prospective studies with exposure monitoring are needed to establish temporality.