Challenge of reducing perinatal mortality in rural Congo: findings of a prospective, population-based study

Each year, an estimated six million perinatal deaths occur worldwide, and 98% of these deaths occur in low- and middle-income countries. These estimates are based on surveys in both urban and rural areas, and they may underrepresent the problem in rural areas. This study was conducted to quantify perinatal mortality, to identify the associated risk factors, and to determine the most common causes of early neonatal death in a rural area of the Democratic Republic of the Congo (DRC). Data were collected on 1,892 births. Risk factors associated with perinatal deaths were identified using multivariate analysis with logistic regression models. Causes of early neonatal deaths were determined by physician-review of information describing death. The perinatal mortality rate was 61 per 1,000 births; the stillbirth rate was 30 per 1,000 births; and the early neonatal death rate was 32 per 1,000 livebirths. Clinically-relevant factors independently associated with perinatal death included: low birthweight [odds ratio (OR)=13.51, 95% confidence interval (CI) 7.82-23.35], breech presentation (OR)=12.41; 95% CI 4.62-33.33), lack of prenatal care (OR=2.70, 95% CI 1.81-4.02), and parity greater than 4 (OR=1.93 95% CI 1.11-3.37). Over one-half of early neonatal deaths (n=37) occurred during the first two postnatal days, and the most common causes were low birthweight/prematurity (47%), asphyxia (34%), and infection (8%). The high perinatal mortality rate in rural communities in the DRC, approximately one-half of which is attributable to early neonatal death, may be modifiable. Specifically, deaths due to breech presentation, the second most common risk factor, may be reduced by making available emergency obstetric care. Most neonatal deaths occur soon after birth, and nearly three-quarters are caused by low birthweight/prematurity or asphyxia. Neonatal mortality might be reduced by targeting interventions to improve neonatal resuscitation and care of larger preterm infants.     

Causes of stillbirths and early neonatal deaths: data from 7993 pregnancies in six developing countries

OBJECTIVE: To report stillbirth and early neonatal mortality and to quantify the relative importance of different primary obstetric causes of perinatal mortality in 171 perinatal deaths from 7993 pregnancies that ended after 28 weeks in nulliparous women. METHODS: A review of all stillbirths and early newborn deaths reported in the WHO calcium supplementation trial for the prevention of pre-eclampsia conducted at seven WHO collaborating centres in Argentina, Egypt, India, Peru, South Africa and Viet Nam. We used the Baird-Pattinson system to assign primary obstetric causes of death and classified causes of early neonatal death using the International classification of diseases and related health problems, Tenth revision (ICD-10). FINDINGS: Stillbirth rate was 12.5 per 1000 births and early neonatal mortality rate was 9.0 per 1000 live births. Spontaneous preterm delivery and hypertensive disorders were the most common obstetric events leading to perinatal deaths (28.7% and 23.6%, respectively). Prematurity was the main cause of early neonatal deaths (62%). CONCLUSIONS: Advancements in the care of premature infants and prevention of spontaneous preterm labour and hypertensive disorders of pregnancy could lead to a substantial decrease in perinatal mortality in hospital settings in developing countries.     

Risks of induction of labour in uncomplicated term pregnancies

Our objective was to evaluate the risks of maternal and perinatal morbidity associated with induction of labour in uncomplicated term pregnancies. We conducted a retrospective cohort study including 7,430 women, not referred from another institution, with a single baby in vertex presentation, and delivering between 38 and 40 weeks of pregnancy. Among these women, 3,546 were excluded for prelabour pregnancy complications. Relative risks (RR), adjusted for parity, were computed to compare 3,353 women who went into labour spontaneously with 531 women whose labour was induced. Induction of labour was found to be associated with a higher risk of caesarean section [RR = 2.4, 95% CI 1.8, 3.4]. Use of non-epidural [RR = 1.5, 95% CI 1.2, 1.8] and of epidural analgesia [RR = 1.4, 95% CI 1.1, 1.7] was more frequent after labour induction. Resuscitation [RR = 1.2, 95% CI 1.0, 1.5], admission to the intensive care unit [RR = 1.6, 95% CI 1.0, 2.4] and phototherapy [RR = 1.3, 95% CI 1.0, 1.6] were more frequent after induction of labour. Results were similar when controlling simultaneously for parity, maternal age, gestational age, year of delivery, birthweight and the physician in charge of delivery in a logistic regression analysis. The results of this study suggests that induction of labour is associated with a higher risk of caesarean section and of some perinatal adverse outcomes. Induction of labour should be reserved for cases where maternal and perinatal benefits outweigh the risk of these complications.     

Partner violence during pregnancy and risk of adverse pregnancy outcomes

The purpose of this cross-sectional study was to investigate the association between partner physical or emotional abuse during pregnancy and pregnancy outcomes including perinatal death, low birthweight and preterm delivery. Women, aged 18-65, who attended one of two large primary care practices from 1997-98 were recruited for this study. Ever pregnant women were asked the frequency of abuse during each pregnancy and details of the pregnancy outcomes. Information regarding abuse during pregnancy and pregnancy outcomes was available for 755 women surveyed who reported a live birth or late fetal death, 14.7% indicated that an intimate partner was violent or abusive toward them during a pregnancy (274 of 1862 pregnancies). Abuse during pregnancy was significantly associated with an increased risk of perinatal death (adjusted relative risk [aRR] = 2.1, 95% confidence interval [CI] 1.3, 3.4) and, among live births, with preterm low birthweight (aRR = 2.4; 95% CI 1.5, 4.0) and term low birthweight (aRR = 1.9; 95% CI 1.0, 3.4). Greater abuse frequency was associated with increased risk. Abuse during pregnancy was associated with perinatal deaths and preterm low birthweight deliveries.     

Risk factors for neonatal and post-neonatal mortality in the Central-West region of Brazil: linkage between live birth and infant death data banks

This article focused on risk factors for neonatal and post-neonatal mortality by linking live births and infant death records. The study was conducted in the municipality of Goiania, in the Central-West region of Brazil. A total of 20,981 live births and 342 infant deaths constitute the retrospective cohort. Neonatal and post-neonatal mortality risks were estimated in this cohort study of live births by logistic regression. In the neonatal period, the highest ORs were for delivery in public hospitals (OR = 2.28; 95% CI 1.57-3.32), pre-term neonates (OR = 8.94; 95% CI 5.85-13.67), and low birth weight (OR = 8.92; 95% CI 5.77-13.79). Cesarean delivery appeared as a protective factor (OR = 0.58; 95% CI 0.43-0.78). For post-neonatal mortality, the highest ORs were for illiterate mothers (OR = 6.25; 95% CI 1.25-31.27), low birth weight (OR = 3.12; 95% CI 1.67-5.84), and delivery in public hospitals (OR = 2.65; 95% CI 1. 13-6.23). The linkage identified socioeconomic variables that were more important risk factors for post-neonatal than neonatal mortality.     

Incidence and Predictors of Mortality among Preterm Neonates Admitted to the Neonatal Intensive Care Unit at Debre Markos Referral Hospital,Northwest Ethiopia

BackgroundPrematurity is the most frequent cause of neonatal death and the second leading cause of under-five mortality. Preterm related complications accounts for 35 % of neonatal deaths within the first week after birth. So far, most studies done in Ethiopia have focused on estimating the prevalence and determinant factors of premature neonatal death. The current study aimed to assess the incidence and predictors of mortality among preterm neonates admitted to neonatal intensive care unit at Debre Markos Referral Hospital.MethodsAn institution-based retrospective follow up study was conducted among premature neonates admitted to Neonatal Intensive Care Unit at Debre Markos Referral Hospital from July 2019 to October 2019. Around 498 patients were selected randomly. A multivariable cox proportional hazards model was fitted to identify predictors of mortality.ResultsA total of 498 preterm babies were followed, and the mean age for follow up at the time of admission to NICU was 15 hours ± 38 SD. Death rate in preterm was estimated to be 27.11% (95% CI: 23.3%, 31.1%). Preterm neonates with gestational age of less than 32 weeks (AHR=1.51; 95% CI: 1.02, 2.24), respiratory distress syndrome (AHR=1.49; 95% CI: 1.03, 2.17), perinatal asphyxia (AHR=1.74, 95% CI: 1.01, 2.76) and congenital malformation (AHR=3.38, 95% CI: 1.21, 8.77) were statistically significant predictors of mortality among preterms.ConclusionThe incidence of death in preterm neonates is relatively low. Gestational age less than 32 weeks, perinatal asphyxia, respiratory distress syndrome and congenital malformation were found as predictors.     

Perinatal mortality in rural Malawi.

Reported are the results of a study to assess the prevalence and risk factors for perinatal death among pregnant women in Malawi over the period 1987-90. There were 264 perinatal deaths among the 3866 women with singleton pregnancies (perinatal mortality rate, 68.3 per 1000 births). Among the risk factors for perinatal mortality were the following: reactive syphilis serology, nulliparity, a late fetal or neonatal death in the most recent previous birth, maternal height < 150 cm, home delivery, and low socioeconomic status. Although unexplained perinatal deaths will continue to occur, perinatal mortality can be reduced if its causes and risk factors in a community are given priority in antenatal and intrapartum care programmes. The following interventions could potentially reduce the perinatal mortality in the study population: screening and treating women with reactive syphilis serology; and management from early labour, by competent personnel in a health facility, of nulliparous women and multiparous women who are short or have a history of a perinatal death.     

Risk factors for neonatal mortality in rural areas of Bangladesh served by a large NGO programme

Neonatal deaths account for about half of all deaths among children under 5 years of age in Bangladesh, making prevention a major priority. This paper reports on a study of neonatal deaths in 12 areas of Bangladesh served by a large NGO programme, which had high coverage of reproductive health outreach services and relatively low neonatal mortality in recent years. The study aimed to identify the main factors associated with neonatal mortality in these areas, with a view to developing appropriate strategies for prevention. A case-control design was adopted for collection of data from mothers whose children, born alive in 2003, died within 28 days postpartum (142 cases), or did not (617 controls). Crude and adjusted odds ratios (AOR) were calculated as estimates of relative risk for neonatal death, using 'neighbourhood' controls (241) and 'non-neighbourhood' controls (376). A similar proportion of case and control mothers had received NGO health education and maternal health services. The main risk factors for neonatal death among 122 singleton babies, based on the two sets of controls, were: complications during delivery [AOR, 2.6 (95% CI: 1.5-4.5) and 3.1 (95% CI: 1.8-5.3)], prematurity [AOR, 7.2 (95% CI: 3.6-14.4) and 8.3 (95% CI: 4.2-16.5)], care for a sick neonate from an unlicensed 'traditional healer' [AOR, 2.9 (95% CI 0.9-9.5 and 5.9 (95% CI: 1.3-26.3)], or care not sought at all [AOR, 23.3 (95% CI: 3.9-137.4)]. The strongest predictor of neonatal death was having a previous sibling not vaccinated against measles [AOR, 5.9 (95% CI: 2.2-15.5) and 12.0 (95% CI: 4.5-31.7)]. The findings of this study indicate the need for identification of babies at high risk and early postpartum interventions (40.2% of the deaths occurred within 24 hours of delivery). Relevant strategies include special counselling during pregnancy for mothers with risk characteristics, training birth attendants in resuscitation, immediate postnatal check-up in the home for high-risk babies identified at delivery, advice for mothers on appropriate care-seeking for sick babies, improving the capacity of sub-district hospitals for emergency obstetric and newborn care, and promotion of institutional deliveries.     

Prenatal and intrapartum events and sudden infant death syndrome

The purpose of this study was to evaluate specific pregnancy and labour and delivery events that may increase the risk of sudden infant death syndrome (SIDS). A matched case-control study was conducted in five counties in southern California, using California death certificate records. The sample consisted of 239 Caucasian, African-American, Hispanic and Asian mothers of SIDS infants and 239 mothers of control infants matched on sex, race, birth hospital and date of birth. Mothers participated in a detailed telephone interview and provided access to obstetric and paediatric records. More case than control mothers reported a family history of anaemia (OR=2.12, P < 0.001). Placental abruptions were strongly associated with SIDS (unadjusted OR=7.94, [95% CI 1.34,47.12]). There was an increased risk of SIDS death associated with maternal anaemia during pregnancy (OR=2.51, [95% CI 1.25,5.03]), while simultaneously adjusting for maternal smoking during pregnancy, maternal years of education and age, parity, infant birthweight, gestational age, medical conditions at birth, infant sleep position and post-natal smoking. Interactions of anaemia and prenatal smoking as well as anaemia and post-natal smoking were not statistically significant. There were no other statistically significant differences between case and control mothers for pregnancy conditions, labour and delivery events (e.g. caesarean sections, anaesthesia, forceps) or newborn complications (e.g. nuchal cord, meconium aspiration). Anaemia and placental abruptions were significantly associated with an increased risk of SIDS; both are circumstances in which a fetus may become hypoxic, thereby compromising the subsequent growth, development and ultimate survival of the infant.     

Perinatal mortality in northern rural Tanzania

The study was conducted to investigate the association between perinatal mortalityand factors relating to nutrition and infections in a rural population in northern Tanzania. A cohort of 3,618 women attending antenatal clinics was registered with background information and the results of antenatal examinations, and followed up after delivery. Stillbirths and neonatal deaths were identified and traced for an interview with the closest relatives. No information on outcome of pregnancy was obtained for seven women, and incomplete information was obtained for 99. The perinatal mortality rate was 27/1,000 births [95% confidence interval (CI) 22/1,000-33/1,000]; 44% were early neonatal deaths; and 56% were stillborn. There was an increased risk of perinatal death among babies with low birth-weight [for babies weighing 2,000-2,499 g, adjusted odds ratio (AOR) 5.8, 95% CI 2.1-15.8, babies below 2,000 g AOR 45.7; 95% CI 18.3-114.1], babies of women with a small arm circumference (below 23 cm, AOR 5.3, 95% CI 1.3-22.2), babies of women with positive VDRL serology (AOR 5.1, 95% CI 1.0-25.7), babies of mothers who had previously lost a baby (AOR 1.9, 95% CI 1.1-3.2), and among babies of nulliparous women (AOR 1.7; 95% CI 1.0-3.0). Infections and nutritional deficiencies should be addressed at antenatal clinics.     

The Contributions of Maternity Care to Reducing Adverse Pregnancy Outcomes: A Cohort Study in Dabat District,Northwest Ethiopia

This study was designed to evaluate the effect of maternity care by skilled providers on the occurrence of adverse pregnancy outcomes. A community-based cohort study was conducted at Dabat district, northwest Ethiopia, from December 1, 2011 to August 31, 2012. During the study period, 763 pregnant women were registered and followed until 42 days of their postpartum period. Use of skilled maternal care was the exposure variable. Reductions in occurrence of serious complications or death (adverse pregnancy outcomes) were used as outcome indicators. Data was collected at four time points; first contact, during the 9th month of pregnancy, within 1 week after delivery and at 42 days of postpartum. The effects of the exposure variable were evaluated by controlling potential confounders using logistic regression. One hundred and fifty-three (21 %) of the women encountered at least one obstetric complication or death during delivery and postpartum period. Hemorrhage and prolonged labor were the major types. Pregnancy outcomes for 41 women (5.6 %) were fetal, neonatal, or maternal deaths. Four or more ANC (antenatal care) visits, <4 ANC visits and delivery by skilled attendant showed 25 % (OR 0.75; 95 % CI 0.25, 2.75), 9 % (OR 0.91; 95 % CI 0.43, 1.69) and 31 % (OR 0.69; 95 % CI 0.36, 1.33) reduction in the occurrence of adverse pregnancy outcomes, respectively. Skilled maternal care showed reduction in adverse pregnancy outcomes (complications and deaths). However, the associations were not significant. Improving the quality of maternity care services and ensuring continuum of care in the health care system are imperative for effective maternal health care in the study area.     

Factors affecting newborn care practices in Bangladesh

Newborn care is of immense importance for the proper development and healthy life of a baby. Although child and infant mortality in South Asia has reduced substantially, the rate of neonatal mortality is still high, although these deaths can be prevented by adopting simple interventions at the community level. The aim of the study was to identify the associated factors which affect newborn care practices. Data for the study were drawn from the Bangladesh Demographic and Health Survey 2007, in which 6150 mothers were considered. The mean age of the mothers was 18 (±3.2) years. A little over 62% of the pregnant women received at least one antenatal check-up during the entire period of their pregnancy. About 70% of deliveries were conducted at home either by unskilled family members or by relatives. A clean instrument was used for cutting the cord of 87% of the newborn babies, while about 34% of them were reported to have had their first bath immediately after delivery. Initiation of breast feeding immediately after birth was practised in only about 19% of the cases. Compared with mothers with no education, those with secondary or higher levels were associated with clean cord care [odds ratio (OR) = 1.3, 95% confidence interval (CI) 1.0, 1.9] and early breast feeding [OR = 1.6, 95% CI 1.2, 2.2]. The study revealed an urgent need to educate mothers, and train traditional birth attendants and health workers on clean delivery practices and early neonatal care. Increasing the number of skilled birth attendants can be an effective strategy to increase safe delivery practices, and to reduce delivery complications.     

History of fetal loss and other adverse pregnancy outcomes in relation to subsequent risk of preterm delivery

Objective: To evaluate the association between maternal reproductive history and preterm delivery. Methods: The 312 preterm delivery cases, studied in aggregate, and in subgroups (spontaneous preterm labor, preterm premature rupture of membranes, medically induced preterm delivery, moderate preterm delivery [gestational age at delivery 34–36 weeks], and very preterm delivery [gestational age at delivery <34 weeks]), were compared with 424 randomly selected women who delivered at term. Maternal medical records provided information on maternal reproductive history, pregnancy outcome, as well as sociodemographic characteristics. Using multivariate logistic regression, we derived maximum likelihood estimates of adjusted odds ratios (OR) and 95% confidence intervals (CI). Results: A history of 2+ miscarriages was ( OR = 2.2; 95% CI 1.2–3.9), but a history of 2+ prior induced abortions (OR = 1.2; 95% CI 0.7–2.0) was not, associated with preterm delivery in the index pregnancy. Analyses of preterm delivery subgroups indicated that a history of 2+ miscarriages was associated with an increasedrisk of spontaneous preterm labor (OR = 2.6; 95% CI 1.2–2.8), preterm premature rupture of membrane (OR = 1.8; 95% 0.7–4.4), and medically induced preterm delivery (OR = 1.9; 95% CI 0.8–4.2), though only the former approached statistical significance. Excess risk of preterm delivery was associated with maternal prior history of delivering a stillborn infant (OR = 10.7), a prior history of delivering a newborn that later died during the neonatal period (OR = 3.2), and a prior history of having a pregnancy complicated by spontaneous preterm delivery (OR = 6.0). Generally these associations were evident for each subgroup of preterm delivery, though inferences were often hindered by our relatively small sample size. Conclusions: These results support the hypothesis that maternal adverse reproductive history is associated with an increased risk of preterm labor and delivery.     

Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors

Background

This study was conducted to determine the relationship between unintended pregnancy and maternal behaviors before, during and after pregnancy.

Study Design

Data were analyzed from a stratified random sample of 9048 mothers who delivered live born infants between 2001 and 2006 and completed the Pregnancy Risk Assessment Monitoring System (PRAMS) survey 2 to 9 months after delivery. Binary and ordinal logistic regression methods with appropriate survey weights were used to control for socio-demographic factors.

Results

Compared to women with intended pregnancies, mothers with unwanted pregnancies were more likely to consume less than the recommended amount of preconception folic acid [adjusted odds ratio (OR) 2.39, 95% confidence interval (CI) 1.7-3.2], smoke prenatally (OR 2.03, 95% CI 1.5-2.9), smoke postpartum (OR 1.86, 95% CI 1.35-2.55) and report postpartum depression (OR 1.98, 95% CI 1.48-2.64); they were less likely to initiate prenatal care during the first trimester (OR 0.34, 95% CI 0.3-0.5) and breastfeed for 8 or more weeks (OR 0.74, 95% CI 0.57-0.97). Compared to women with intended pregnancies, women with mistimed pregnancies were also more likely to consume inadequate folic acid, delay prenatal care and report postpartum depression.

Conclusion

Even after controlling for multiple socio-demographic factors, unwanted and mistimed pregnancies were associated with unhealthy perinatal behaviors.     

Early postpartum maternal morbidity among rural women of Rajasthan, India: a community-based study

The first postpartum week is a high-risk period for mothers and newborns. Very few community-based studies have been conducted on patterns of maternal morbidity in resource-poor countries in that first week. An intervention on postpartum care for women within the first week after delivery was initiated in a rural area of Rajasthan, India. The intervention included a rigorous system of receiving reports of all deliveries in a defined population and providing home-level postpartum care to all women, irrespective of the place of delivery. Trained nurse-midwives used a structured checklist for detecting and managing maternal and neonatal conditions during postpartum-care visits. A total of 4,975 women, representing 87.1% of all expected deliveries in a population of 58,000, were examined in their first postpartum week during January 2007-December 2010. Haemoglobin was tested for 77.1% of women (n=3,836) who had a postnatal visit. The most common morbidity was postpartum anaemia--7.4% of women suffered from severe anaemia and 46% from moderate anaemia. Other common morbidities were fever (4%), breast conditions (4.9%), and perineal conditions (4.5%). Life-threatening postpartum morbidities were detected in 7.6% of women--9.7% among those who had deliveries at home and 6.6% among those who had institutional deliveries. None had a fistula. Severe anaemia had a strong correlation with perinatal death [p<0.000, adjusted odds ratio (AOR)=1.99, 95% confidence interval (CI) 1.32-2.99], delivery at home [p<0.000, AOR=1.64 (95% CI 1.27-2.15)], socioeconomically-underprivileged scheduled caste or tribe [p<0.000, AOR=2.47 (95% CI 1.83-3.33)], and parity of three or more [p<0.000, AOR=1.52 (95% CI 1.18-1.97)]. The correlation with antenatal care was not significant. Perineal conditions were more frequent among women who had institutional deliveries while breast conditions were more common among those who had a perinatal death. This study adds valuable knowledge on postpartum morbidity affecting women in the first few days after delivery in a low-resource setting. Health programmes should invest to ensure that all women receive early postpartum visits after delivery at home and after discharge from institution to detect and manage maternal morbidity. Further, health programmes should also ensure that women are properly screened for complications before their discharge from hospitals after delivery.     

Obstetrical volume and early neonatal mortality in preterm infants

Objective Regionalised perinatal care with antenatal transfer of high risk pregnancies to Level III centres is beneficial. However, levels of care are usually not linked to caseload requirements, which remain a point for discussion. We aimed to investigate the impact of annual delivery volume on early neonatal mortality among very preterm births. Methods All neonates with gestational age 24–30 weeks, born 1991–1999 in Lower Saxony were included into this population-based cohort study (n = 5,083). Large units were defined as caring for more than 1,000 deliveries/year, large NICUs as those with at least 36 annual very low birthweight (<1,500 g, VLBW) admissions. Main outcome criterion was mortality until day 7. Adjusted Odds Ratios (adj. OR) and 95% confidence intervals (CI) were calculated based on generalised estimating equation models, accounting for correlation of individuals within units. Results Within the first week of life, 20.6% of all neonates deceased; 10.2% were stillbirths, 3.7% died in the delivery unit, and 6.7% in the NICU. The crude OR for early neonatal mortality after having been delivered in a small delivery unit (excluding stillbirths) was 1.36 (95%CI 1.04–1.78; adj. OR 1.16 (0.82–1.63)). It increased to 1.96 (1.54–2.48; adj. OR 1.21 (0.86–1.70)) after the inclusion of stillbirths. Conclusion This study has shown a slight, but non-significant association between obstetrical volume and early neonatal mortality. In future studies the impact of caseload on outcome may become more evident when referring to high-risk patients instead of to the overall number of deliveries.     

Determinants of Small for Gestational Age Birth at Term

Background: Being born small for gestational age (SGA) is an indicator of intrauterine growth restriction (IUGR) and later health risks. This study investigated determinants of severe and moderate SGA (respectively, birthweight <3rd percentile and 3rd to <10th percentile for gestational age and sex). Methods: A total of 2195 term pregnancies from a prospective cohort were studied. Prenatal data arose from maternal interview at 10–22 weeks of gestation and perinatal data were collected from hospital charts. Severe and moderate SGA were classified by Canadian population standards. Risk factors for SGA were identified from fitting multivariable logistic regression models. Results: Multivariable associations with severe SGA were: maternal age ≥ 35 [odds ratio (OR) 3.2 [95% confidence interval (CI) 1.4, 6.9]], maternal smoking during pregnancy (OR 5.3 [95% CI 2.4, 11.7]), preeclampsia (OR 4.6 [95% CI 1.6, 13.2]) and threatened preterm labour (OR 3.9 [95% CI 1.3, 11.4]). Primiparity was associated with both severe and moderate SGA with OR 2.4 [95% CI 1.1, 5.1] and OR 1.9 [95% CI 1.3, 2.9] respectively. Underweight pre‐pregnancy body mass index was associated with moderate SGA (OR 2.4 [95% CI 1.2, 5.0]). Inclusion of placental weight, in the final model attenuated the associations. Conclusions: This study demonstrated different determinants for severe and moderate SGA. We speculate that the majority of severe SGA infants are IUGR while moderate SGA infants may be a mixture of IUGR and constitutionally small newborns. This study has also contributed evidence linking preterm labour and SGA as two, potentially related, outcomes of overlapping causal mechanisms reflective of ischaemic placental disease.     

Racial disparity in pregnancy-related mortality following a live birth outcome

PURPOSE: African-American women have a 2- to 4-fold increased risk of pregnancy-related death compared with Caucasian women. We conducted this study to determine if differences in a combination of socioeconomic and medical risk factors may explain this racial disparity in pregnancy-related death. METHODS: Pregnancy-related deaths of African-American (N=60) and Caucasian (N=47) women were identified from review of pregnancy-associated deaths (N=400) ascertained through cause of death on death certificates, electronic linkage of birth and death files, and review of the hospital discharge database for the State of North Carolina, during the period between 1992 and 1998. Controls (N=3404) were randomly selected from all live births for the same 7-year period. Logistic regression was used to model the association between race and pregnancy-related death. RESULTS: The unadjusted odds ratio (OR) for pregnancy-related death for African-Americans compared with Caucasians was 3.07 (95% confidence interval [CI], 2.08, 4.54). After controlling for gestational age at delivery, maternal age, income, hypertension, and receipt of prenatal care, African-American race remained a significant predictor variable (OR 2.65 [95% CI 1.73, 4.07]). CONCLUSIONS: Our analysis confirms that there is a strong association between race and pregnancy-related death, even after adjusting for potential predictors and confounders.     

Neonatal mortality of low-birth-weight infants in Bangladesh

OBJECTIVE: To ascertain the role of low birth weight (LBW) in neonatal mortality in a periurban setting in Bangladesh. METHODS: LBW neonates were recruited prospectively and followed up at one month of age. The cohort of neonates were recruited after delivery in a hospital in Dhaka, Bangladesh, and 776 were successfully followed up either at home or, in the event of early death, in hospital. FINDINGS: The neonatal mortality rate (NMR) for these infants was 133 per 1000 live births (95% confidence interval: 110-159). The corresponding NMRs (and confidence intervals) for early and late neonates were 112 (91-136) and 21 (12-33) per thousand live births, respectively. The NMR for infants born after fewer than 32 weeks of gestation was 769 (563-910); and was 780 (640-885) for infants whose birth weights were under 1500 g. Eighty-four per cent of neonatal deaths occurred in the first seven days; half within 48 hours. Preterm delivery was implicated in three-quarters of neonatal deaths, but was associated with only one-third of LBW neonates. CONCLUSION: Policy-relevant findings were: that LBW approximately doubles the NMR in a periurban setting in Bangladesh; that neonatal mortality tends to occur early; and that preterm delivery is the most important contributor to the NMR. The group of infants most likely to benefit from improvements in low-cost essential care for the newborn accounted for almost 61% of neonatal mortalities in the cohort.     

A prospective study of maternal,fetal and neonatal deaths in low- and middle-income countries

Objective

To quantify maternal, fetal and neonatal mortality in low- and middle-income countries, to identify when deaths occur and to identify relationships between maternal deaths and stillbirths and neonatal deaths.

Methods

A prospective study of pregnancy outcomes was performed in 106 communities at seven sites in Argentina, Guatemala, India, Kenya, Pakistan and Zambia. Pregnant women were enrolled and followed until six weeks postpartum.

Findings

Between 2010 and 2012, 214 070 of 220 235 enrolled women (97.2%) completed follow-up. The maternal mortality ratio was 168 per 100 000 live births, ranging from 69 per 100 000 in Argentina to 316 per 100 000 in Pakistan. Overall, 29% (98/336) of maternal deaths occurred around the time of delivery: most were attributed to haemorrhage (86/336), pre-eclampsia or eclampsia (55/336) or sepsis (39/336). Around 70% (4349/6213) of stillbirths were probably intrapartum; 34% (1804/5230) of neonates died on the day of delivery and 14% (755/5230) died the day after. Stillbirths were more common in women who died than in those alive six weeks postpartum (risk ratio, RR: 9.48; 95% confidence interval, CI: 7.97–11.27), as were perinatal deaths (RR: 4.30; 95% CI: 3.26–5.67) and 7-day (RR: 3.94; 95% CI: 2.74–5.65) and 28-day neonatal deaths (RR: 7.36; 95% CI: 5.54–9.77).

Conclusion

Most maternal, fetal and neonatal deaths occurred at or around delivery and were attributed to preventable causes. Maternal death increased the risk of perinatal and neonatal death. Improving obstetric and neonatal care around the time of birth offers the greatest chance of reducing mortality.