Neonatal mortality and morbidity after elective cesarean delivery versus routine expectant management: a decision analysis

A number of competing risks and benefits influence the rates of neonatal morbidity and mortality in elective cesarean delivery versus expectant management. To compare these rates, we developed complex decision trees to model the expected outcomes among hypothetical cohorts of 1,000,000 uncomplicated pregnancies undergoing elective cesarean delivery versus 1,000,000 comparable pregnancies undergoing routine pregnancy management. A separate tree was created for each complication, including neonatal death, respiratory morbidity, intracranial hemorrhage, and brachial plexus injury. We found that neonatal mortality was increased among elective cesarean deliveries, but perinatal mortality was higher with routine expectant management due to fetal deaths. Respiratory morbidity was substantially more common among infants delivered by elective cesarean delivery, whereas intracranial hemorrhage and brachial plexus injury were less common. We conclude that the fetal/neonatal impact of elective cesarean is mixed, but any improvement in perinatal health is likely to be small.     

Neonatal mortality in Sri Lanka: Timing,causes and distribution

Abstract

Objective.?To evaluate the timing, causes and distribution of neonatal deaths in Sri Lanka, to provide information for policy makers, to undertake appropriate measures to achieve the Millennium Development Goals.

Methods.?All neonatal deaths, reported to the Registrar General's Office, Sri Lanka, from 1997 to 2001, were included in the analysis.

Results.?During this 5-year period, 17,946 neonatal deaths have occurred, of them 90.5% have occurred during the first week of life. The leading causes were preterm deliveries (33.2%), infections (19.8%) and cardiac anomalies (17.4%). The neonatal mortality rates (NMR) were higher in districts with specialised neonatal care facilities and high concentration of estates.

Conclusions.?Approximately 3600 neonates die in Sri Lanka annually, even though it has a lower NMR compared to rest of the South Asia. Neonatal deaths were higher in the major cities and in the estate sector. The majority of neonatal deaths were due to complications of preterm birth, neonatal sepsis and cardiac anomalies.     

Preeclampsia in Jordan: incidence,risk factors,and its associated maternal and neonatal outcomes

Objectives: To estimate the incidence of preeclampsia among Jordanian pregnant women, determine its risk factors and its associated neonatal morbidity and mortality.

Methods: The study is a part of a comprehensive national study of perinatal mortality that was conducted in Jordan. This study included all women who gave birth in the selected hospitals during the study period. Maternal and medical conditions during pregnancy and neonatal outcomes were compared between women who developed preeclampsia and who did not.

Results: This study included a total of 21,928 women. The overall incidence rate of preeclampsia was 1.3%. Obesity (OR?=?2.6) and high blood pressure (OR?=?11.9) were significantly associated with increasing odds of preeclampsia. The risk of preeclampsia was 2.3 times higher in first pregnancies than that in second or more pregnancies. The rates of low birth weight (LBW) delivery (32.5% vs. 8.3%), and prematurity (30.8% vs. 7%), and the neonatal mortality rate (81 vs. 12 per 1000 live births) were significantly higher among women with preeclampsia.

Conclusions: The overall incidence rate of preeclampsia was 1.3%. Preeclampsia was significantly associated with maternal and neonatal morbidity and mortality as well as increasing vaginal operative delivery, cesarean section, LBW, and birth asphyxia.     

Perinatal mortality rate in the Netherlands compared to other European countries: A secondary analysis of Euro-PERISTAT data

Objective

the poor perinatal mortality ranking of the Netherlands compared to other European countries has led to questioning the safety of primary care births, particularly those at home. Primary care births are only planned at term. We therefore examined to which extent the perinatal mortality rate at term in the Netherlands contributes to its poor ranking.

Design

secondary analyses using published data from the Euro-PERISTAT study.

Setting and participants

women that gave birth in 2004 in the 29 European regions and countries called 'countries' included in the Euro-PERISTAT study (4,328,441 women in total and 1,940,977 women at term).

Methods

odds ratios and 95% confidence intervals were calculated for the comparison of perinatal mortality rates between European countries and the Netherlands, through logistic regression analyses using summary country data.

Main outcome measures

combined perinatal mortality rates overall and at term. Perinatal deaths below 28 weeks, between 28 and 37 weeks and from 37 weeks onwards per 1000 total births.

Findings

compared to the Netherlands, perinatal mortality rates at term were significantly higher for Denmark and Latvia and not significantly different compared to seven other countries. Eleven countries had a significantly lower rate, and for eight the term perinatal mortality rate could not be compared. The Netherlands had the highest number of perinatal deaths before 28 weeks per 1000 total births (4.3).

Key conclusions

the relatively high perinatal mortality rate in the Netherlands is driven more by extremely preterm births than births at term. Although the PERISTAT data cannot be used to show that the Dutch maternity care system is safe, neither should they be used to argue that the system is unsafe. The PERISTAT data alone do not support changes to the Dutch maternity care system that reduce the possibility for women to choose a home birth while benefits of these changes are uncertain.     

The changing pattern of perinatal mortality and causes of death in central Anatolian region of Turkey

In this study, the perinatal mortality is presented in 2009 compared to 1998. Changing patterns of the perinatal mortality rate (PNMR), the stillbirth rate (SBR), early neonatal mortality rate (ENMR) and the causes of the perinatal mortality in Zekai Tahir Burak Women’s Health Education and Research Hospital (ZTBH) were described. This is the largest maternity hospital of Ankara in the central Anatolian region of Turkey. The total deliveries were 22,777 and 18,567 in 1998 and 2009, respectively. PNMR was 27.7 per 1000, and SBR was 23.7 per 1000 total births. ENMR was 4 per 1000 in 1998. PNMR is 20.7 per 1000, and SBR was 16.3 per 1000 and ENMR was 4.6 per 1000 total births in 2009. It is important to know the causes of mortality. In this study, the causes of perinatal deaths were classified according to the Wigglesworth classification. Antepartum stillbirth (62.3%) was the most frequent cause in 1998. Perinatal asphyxia is the majority (46.6%) of the perinatal deaths in 2009. This study shows that even prenatal care is getting better, obstetric care as well as close follow-up throughout the intrapartum period and diminishing the preterm delivery rate is also important for preventing and reducing perinatal mortality.     

Neonatal outcomes of successful VBAC among obese and super-obese mothers

Objective: We sought to evaluate neonatal morbidity and mortality among women who experienced successful vaginal births after previous cesarean delivery (VBAC) by obesity subtypes. Methods: Missouri maternally linked cohort data files were utilized. Analyses were restricted to successful singleton VBACs. Main study outcomes were neonatal death and neonatal morbidity. Risk estimates were obtained using logistic and hazards regression modeling. Results: A total of 30,017 singleton births met inclusion criteria. The prevalence of VBAC was 2.3%. The neonatal death rate (per 1000) by maternal obesity subtype was 4.1 for moderate, 3.2 for severe, 4.5 for extreme and 14.3 for super-obese. The overall risk for neonatal morbidity was 56% greater among obese women when compared with normal weight women, with risk estimates increased incrementally with ascending body mass index (BMI) (p for trend < 0.01). Conclusion: Infants of obese women undergoing successful VBAC are at elevated risk for neonatal morbidity, and the risk increases progressively with ascending BMI.     

Emergency peripartum hysterectomy in Northern Jordan: indications and obstetric outcome (an 8-year review)

Objective To review cases of emergency peripartum hysterectomy regarding their incidence, risk factors, indications and complications and their results were carefully analysed.Materials and methods A retrospective study of cases of emergency peripartum hysterectomy which were performed in the period between February 1994 and February 2002 at the Princess Badeea Teaching Hospital in Northern Jordan. Demographic and clinical data were extracted and closely interpretedResults In the study period there were a 70,252 deliveries and 61 cases of emergency peripartum hysterectomies. The overall incidence was 0.87 peripartum hysterectomies per 1,000 deliveries. There were 50 cases (82%) delivered by caesarean section and 11 cases (18%) were delivered vaginally. Caesarean hysterectomy was performed in 50 cases and postpartum hysterectomy was performed in 11 cases. Total hysterectomy was performed in 39 cases (64%) and subtotal hysterectomy was performed in 22 cases (36%). The main indications for hysterectomy were morbidly adherent placenta (47.5%), ruptured uterus (27.9%) and uncontrollable haemorrhage from uterine atony (21.3%). There were two maternal deaths and 7 cases of stillbirths and 4 cases of early neonatal deaths.Conclusion Peripartum hysterectomy is a dramatic with high risk but a life saving operation. It is usually associated with significant maternal and fetal morbidity and mortality. Obstetricians should identify patients at risk and anticipate the procedure and complications, as early intervention and proper management facilitate optimal outcome.     

Improving maternal mortality reporting at the community level with a 4-question modified reproductive age mortality survey (RAMOS)

Objective

To investigate the identification of maternal deaths at the community level using the reproductive age mortality survey (RAMOS) in all households in which a women of reproductive age (WRA) died and to determine the most concise subset of questions for identifying a pregnancy-related death for further investigation.

Methods

A full RAMOS survey was conducted with the families of 46 deceased WRA who died between 2005 and July 2009 and was compared with the cause of death confirmed by the maternal mortality review committee to establish the number of maternal mortalities. The positive predictive value (PPV) of each RAMOS question for identifying a maternal death was determined.

Results

Compared with years of voluntary reporting, active surveillance for maternal deaths doubled their identification. In addition, 4 questions from the full RAMOS have the highest PPV for a maternal death including the question: "Was she pregnant within the last 6 weeks?" which had a 100% PPV and a 100% negative predictive value.

Conclusion

Active identification of maternal mortality at the community level by using a 4-question modified RAMOS that is systematically administered in the local language by health workers can increase understanding of the extent of maternal mortality in rural Ghana.     

Neonatal Outcomes in the Birth Center Setting: A Systematic Review

Introduction

This systematic review investigates the effect of the birth center setting on neonatal mortality in economically developed countries to aid women and clinicians in decision making.

Methods

We searched the Google Scholar, CINAHL, and PubMed databases using key terms birth/birthing center or out of hospital with perinatal/neonatal outcomes. Ancestry searches identified additional studies, and an alert was set for new publications. We included primary source studies in English, published after 1980, conducted in a developed country, and researching planned birth in centers with guidelines similar to American Association of Birth Centers standards. After initial review, we conducted a preliminary analysis, assessing which measures of neonatal health, morbidity, and mortality were included across studies.

Results

Neonatal mortality was selected as the sole summary measure as other measures were sporadically reported or inconsistently defined. Seventeen studies were included, representing at least 84,500 women admitted to a birth center in labor. There were substantial differences of study design, sampling techniques, and definitions of neonatal outcomes across studies, limiting conclusive statements of the effect of intrapartum care in a birth center. No reviewed study found a statistically increased rate of neonatal mortality in birth centers compared to low‐risk women giving birth in hospitals, nor did data suggest a trend toward higher neonatal mortality in birth centers. As in all birth settings, nulliparous women, women aged greater than 35 years, and women with pregnancies of more than 42 weeks’ gestation may have an increased risk of neonatal mortality.

Discussion

There are substantial flaws in the literature concerning the effect of birth center care on neonatal outcomes. More research is needed on subgroups at risk of poor outcomes in the birth center environment. To expedite research, consistent use of national and international definitions of perinatal and neonatal mortality within data registries and greater detail on adverse outcomes would be beneficial.     

Trends in twin neonatal mortality rates in the United States, 1989 through 1999: influence of birth registration and obstetric intervention

OBJECTIVE: We sought to evaluate the contributions of changes in birth registration, labor induction, and cesarean delivery on trends in twin neonatal mortality rates. STUDY DESIGN: We conducted a population-based, retrospective cohort study of twin live births, using linked birth-infant death data in the United States (1989-1999). Relative risks and 95% confidence intervals that quantified changes in neonatal (0-27 days) mortality rates were derived from ecologic logistic regression models that were fit after aggregation of the data by each state in the United States. RESULTS: The frequency of live born twins who weighed <500 g increased 72%, from 0.7% in 1989 to 1.2% in 1999, of live born twins who weighed 500 to 749 g and 750 to 999 g increased by 55% and 28%, respectively, between 1989 and 1999. Preterm birth rates increased by 19%, from 46.2% in 1989 to 57.2% in 1999. The rate of labor induction increased from 5.8% to 13.9%, and the cesarean delivery rate increased from 49.8% to 56.3%. Between 1989 to 1991 and 1997 to 1999, the crude neonatal mortality rates among twins who weighed >or=500 g declined by 37% (95% CI, 35%-40%) from 21.5 to 13.6 per 1000 twin live births. Adjustments for preterm labor induction, preterm cesarean delivery, term labor induction, term cesarean delivery, and sociodemographic factors had little influence on neonatal mortality rate trends. CONCLUSION: Increases in preterm birth because of obstetric intervention among twins have not led to increases in twin neonatal mortality rates in the United States.     

Fifty Years of Progress in Neonatal and Maternal Transport for Specialty Care

Specialty care for preterm and critically ill infants has evolved over many years. Neonatal intensive care nurseries were developed, and physicians and nurses learned how to provide intensive care for these infants. Neonatal and maternal (in utero) transport to tertiary centers became common in regionalized systems of care to facilitate the specialized care of high-risk neonates when childbirth occurred in settings without specialized personnel or equipment. Annually, nearly 70,000 neonatal transports occur in the United States. Although specialty care helps reduce rates of neonatal mortality, racial disparities and disparities between urban and rural areas exist. The purpose of this article is to review the progress achieved in neonatal and maternal transport over the past 50 years. The knowledge developed can be used to improve the care provided to women, their fetuses, and infants.     

Determinants of perinatal mortality in Nigeria

Objective

To determine risk factors for perinatal mortality among hospital-based deliveries in Nigeria.

Methods

The WHO Global Maternal and Perinatal Health Survey was implemented in Nigeria as a first step in establishing a global system for monitoring maternal and perinatal health. Twenty-one health facilities with more than 1000 deliveries annually were selected by a stratified multistage cluster sampling strategy. Information was recorded on all women who delivered and their neonates within a 3-month period.

Results

Overall, there were 9208 deliveries, comprising 8526 live births, 369 fresh stillbirths, 282 macerated stillbirths, 70 early neonatal deaths, and 721 perinatal deaths. The stillbirth and perinatal mortality rates were, respectively, 71 and 78 per 1000 deliveries; the early neonatal death rate was 8 per 1000 live births. Approximately 10% of all newborns weighed less than 2500 g, and 12.3% were born at less than 37 weeks of gestation. Predictors of perinatal mortality were mother's age, lack of prenatal care, unbooked status, prematurity, and birth asphyxia.

Conclusion

The perinatal mortality rate remains unacceptably high in Nigeria. Fresh stillbirth accounted for most perinatal deaths. Interventions to improve the utilization and quality of prenatal care, in addition to the quality of intrapartum care, would considerably reduce perinatal death.     

The higher the educational level of the first-time mother,the lower the fetal and post-neonatal but not the neonatal mortality in Belgium (Flanders)

Objective

To assess, in a homogenous population of primiparous women, how fetal and infant (=first year of life) mortality varied by the mothers’ level of education.

Study design

We conducted an observational study in Flanders (Northern Belgium) involving 170,948 primiparous women who delivered in Flanders during the period 1999–2006, and their 174,495 babies. We linked the maternal education (3 levels) with a series of obstetrical and perinatal events, with special emphasis on fetal and infant death. A logistic regression analysis was performed to adjust for confounders.

Results

The incidence of fetal (0.21% – high level of education; 0.35% – medium level; 0.84% – low level) and infant mortality (0.32%; 0.41%; 0.70%, respectively), followed an inverse maternal educational gradient: higher with a lower level of education. However, neonatal death (0–27 days) was independent of the educational level of the mother. The age of the woman at delivery, the use of assisted reproductive technology and the incidence of twin birth increased while the rates of preterm birth (7.7% – high level; 8.9% – medium level; 10% – low level) and low birth weight (7.2%; 9.5%; 11.8%, respectively) decreased with the mother's educational level.

Conclusion

Perinatal and obstetrical outcome differ according to the level of the education of the mother, which is a determinant of the incidence of fetal and post-neonatal death but not of early and late neonatal death (0–27 days).     

Risk factors and neonatal/infant mortality risk of small-for-gestational-age and preterm birth in rural Nepal

Objective: Our study seeks to elucidate risk factors for and mortality consequences of small-for-gestational-age (SGA) and preterm birth in rural Nepal. In contrast with previous literature, we distinguish the epidemiology of SGA and preterm birth from each other.

Methods: We analyzed data from a maternal micronutrient supplementation trial in rural Nepal (n?=?4130). We estimated adjusted risk ratios (aRR) for risk factors of SGA and preterm birth, and aRRs for the associations between SGA/preterm birth and neonatal/infant mortality. We used mutually exclusive categories of term-appropriate-for-gestational-age (AGA), term-SGA, preterm-AGA, and preterm-SGA (with term-AGA as reference) in our analyses.

Results: Stunted (<145?cm) and wasted (<18.5?kg/m²) women both had increased risk of having term-SGA (aRR 1.36, 95% CI: 1.14-1.61, aRR 1.22, 95% CI: 1.09–1.36 respectively) and preterm-SGA (aRR 2.48, 95% CI: 1.29–4.74, aRR 1.99, 95% CI: 1.33–2.97 respectively), but not preterm-AGA births. Similar results were found for low maternal weight gain per gestational week. Those born preterm-SGA generally experienced the highest neonatal and infant mortality risk, although term-SGA and preterm-AGA newborns also had statistically significantly high mortality risks compared to term-AGA babies.

Conclusions: SGA and preterm birth have distinct risk factors and mortality patterns. Maternal chronic and acute malnutrition appear to be associated with SGA outcomes. Because of high SGA prevalence in South Asia and the increased neonatal and infant mortality risk associated with SGA, there is an urgent need to intervene with effective interventions.