Ethnic differences in perinatal mortality. A perinatal audit on the role of substandard care

OBJECTIVES: The objective was to investigate the contribution of substandard care to ethnic inequalities in perinatal mortality. STUDY DESIGN: Perinatal audit in Amsterdam, the Netherlands. The study population consisted of 137 consecutive perinatal death cases (16 weeks GA-28 days after delivery). A standardized procedure to establish the cause of death and substandard care by perinatal audit was developed. The main outcome measures were perinatal mortality rates in ethnic groups, cause of death classified by extended Wigglesworth classification, presence of substandard care (unlikely to be, possibly or likely to be related to perinatal death), and component of care considered to be substandard. RESULTS: In Surinamese and other non-Western mothers (mainly from Ghana) perinatal mortality, beyond 16 weeks' gestation, was statistically significantly higher than among native Dutch mothers. (4.01, 2.50, and 1.07%, respectively). In Surinamese and Moroccan mothers, we observed a higher rate of early preterm deliveries. The prevalence of substandard care differed statistically significantly among ethnic groups (p=0.034), with the highest prevalence among Surinamese mothers. These differences were especially apparent in the prevalence of (more) maternal substandard care factors among Surinamese and Moroccan mothers. These factors consisted of a later start date for antenatal care or a later notification by the caregiver about obstetrical problems (e.g. rupturing of membranes, decrease in foetal movements). CONCLUSIONS: The higher perinatal mortality in Surinamese and other non-Western groups is mainly due to a higher rate of early preterm deliveries. No differences in care were observed among ethnic groups during labour and delivery. Among Surinamese mothers, however, the results indicate that substandard care with maternal involvement plays a role in explaining their higher perinatal mortality rates.     

Implementation of the Zambia Electronic Perinatal Record System for comprehensive prenatal and delivery care

Objective

To characterize prenatal and delivery care in an urban African setting.

Methods

The Zambia Electronic Perinatal Record System (ZEPRS) was implemented to record demographic characteristics, past medical and obstetric history, prenatal care, and delivery and newborn care for pregnant women across 25 facilities in the Lusaka public health sector.

Results

From June 1, 2007, to January 31, 2010, 115 552 pregnant women had prenatal and delivery information recorded in ZEPRS. Median gestation age at first prenatal visit was 23 weeks (interquartile range [IQR] 19-26). Syphilis screening was documented in 95 663 (83%) pregnancies: 2449 (2.6%) women tested positive, of whom 1589 (64.9%) were treated appropriately. 111 108 (96%) women agreed to HIV testing, of whom 22% were diagnosed with HIV. Overall, 112 813 (98%) of recorded pregnancies resulted in a live birth, and 2739 (2%) in a stillbirth. The median gestational age was 38 weeks (IQR 35-40) at delivery; the median birth weight of newborns was 3000 g (IQR 2700-3300 g).

Conclusion

The results demonstrate the feasibility of using a comprehensive electronic medical record in an urban African setting, and highlight its important role in ongoing efforts to improve clinical care.     

A Standard Perinatal Care Record in Canada: Justification,Acceptability and Feasibility

Use of a standard perinatal record will serve the needs of health care consumers and providers who require expedient communication of all aspects of care. The universal use of a standard record will provide accurate information on which to base health care policy and management strategies for health care planners and researchers. Acceptance of a standard record is dependent on involvement of all users of the record in its development, collection of high quality data and designation of a minimum data set for a national perinatal database. Experience in the Nordic countries has shown that a national standard record is feasible and serves well as a data collection instrument. The Canadian Perinatal Surveillance System is in the process of developing a standard perinatal record for Canada.     

Emergency obstetric surgery by non-physician clinicians in Tanzania

Objective

To calculate the met need for comprehensive emergency obstetric care (CEmOC) in 2 Tanzanian regions (Mwanza and Kigoma) and to document the contribution of non-physician clinicians (assistant medical officers [AMOs]) and medical officers (MOs) with regard to meeting the need for CEmOC.

Methods

All hospitals in the 2 regions were visited to determine the proportion of major obstetric interventions performed by AMOs and MOs. All deliveries (n = 38 758) in these hospitals in 2003 were reviewed. The estimated met need for emergency obstetric care (EmOC) was calculated using UN process indicators, as was the contribution to that attainment by AMOs. Hospital case fatality rates were also determined.

Results

Estimated met need was 35% in Mwanza and 23% in Kigoma. AMOs operating independently performed most major obstetric surgery. Outside of the single university hospital, AMOs performed 85% of cesareans and high proportions of other obstetric surgeries. The case fatality rate was 2.0% in Mwanza and 1.2% in Kigoma.

Conclusion

AMOs carried most of the burden of life-saving EmOC—particularly cesarean deliveries—in the regions investigated. Case fatality was close to the 1% target set by the UN process indicators, but met need was far below the goal of 100%.     

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.     

Death audit in the neonatal ICU of a tertiary care hospital in Bangladesh: a retrospective chart review

Background: Expectant reduction of neonatal mortality and formulation of preventive strategies can only be achieved by analysis of risk factors in a particular setting. This study aimed to document incidence of neonatal death and to analyze the risk factors associated with neonatal death.

Methods: This retrospective study was carried out in department of Neonatology, Bangabandhu Sheikh Mujib Medical University (BSMMU) over a 12-month period from January to December 2015. The newborns that died within 28 d of life were defined as “Cases” and “Control” were the surviving newborn discharged to home as healthy. Two birth weight and gestational age matched controls were taken for each case. Maternal, obstetric, and newborn characteristics were analyzed between both the groups. Data analysis was performed using SPSS version 20.0 (SPSS Inc., Chicago, IL). A probability of Results: During the study period, the proportion of death was 9.6% (64/612). Both in Chi-square analysis and in logistic regression analysis, less than four antenatal visits (odds ratio (OR) 2.78; 95% CI: 1.23–6.28, p?=?.014) and sepsis (OR 2.37; 95% CI: 1.07–5.26, p?=?.034) were found to be independent risk factors for deaths, whereas LUCS found to be protective for deaths (OR 0.40; 95% CI: 0.19–0.83, p?=?.015).

Conclusion: In conclusion, less than four antenatal visits and presence of sepsis were found to be independent risk factors whereas LUCS protective of newborn death.     

Seizures in the Nigerian neonate: Perinatal factors

A prospective study of 55 infants with neonatal seizures admitted to the Special Care Baby Unit of the University of Benin Teaching Hospital over a 5.5-year period revealed that perinatal asphyxia and hypoglycemia were the principal aetiologic factors in about 71% of the cases. The most frequently encountered seizure types were unilateral clonic (51.5%). Generalized clonic and massive generalized myoclonic seizures were found in 14 (25.5%) and seven (12.7%) cases, respectively, and subtle seizures in three.The overall incidence was $\text{3.5}\text{1000}$ live births, with a preponderance of male infants in the seizure population, among whom preterm infants were significantly more common.The mortality, (34.5%) was closely related to the etiology. Since the associated adverse perinatal events are largely preventable, improved prenatal and perinatal health care delivery should lead to a decline in the frequency of neonatal seizures.     

Avoidable risk factors in perinatal deaths: a perinatal audit in South Australia

OBJECTIVES: To analyse risk factors of perinatal death, with an emphasis on potentially avoidable risk factors, and differences in the frequency of suboptimal care factors between maternity units with different levels of care. METHODS: Six hundred and eight pregnancies (2001-2005) in South Australia resulting in perinatal death were described and compared to 86 623 live birth pregnancies. RESULTS: Two hundred and seventy cases (44.4%) were found to have one or more avoidable maternal risk factors, 31 cases (5.1%) had a risk factor relating access to care, while 68 cases (11.2%) were associated with deficiencies in professional care. One hundred and four women (17.1% of cases) presented too late for timely medical care: 85% of these did have a sufficient number of antenatal visits. The following independent maternal risk factors for perinatal death were found: assisted reproductive technology (adjusted odds ratio (AOR) 3.16), preterm labour (AOR 22.05), antepartum haemorrhage (APH) abruption (AOR 6.40), APH other/unknown cause (AOR 2.19), intrauterine growth restriction (AOR 3.94), cervical incompetence (AOR 8.89), threatened miscarriage (AOR 1.89), pre-existing hypertension (AOR 1.72), psychiatric disorder (AOR 1.85) and minimal antenatal care (AOR 2.89). The most commonly found professional care deficiency in cases was the failure to act on or recognise high-risk pregnancies/complications, found in 49 cases (8.1%). CONCLUSION: Further improvements in perinatal mortality may be achieved by greater emphasis on the importance of antenatal care and educating women to recognise signs and symptoms that require professional assessment. Education of maternity care providers may benefit from a further focus on how to recognise and/or manage high-risk pregnancies.     

Perinatal outcome in women with severe chronic hypertension during the second half of pregnancy.

OBJECTIVES: To determine the perinatal outcome associated with severe chronic hypertension (SCH) in pregnancies of > or =20 weeks' gestation. METHODS: A retrospective analysis of data obtained prospectively of patients with SCH (> or =160/110 mmHg) who were hospitalized and delivered during a 5-year period. Each patient received intensive monitoring of the clinical status throughout the hospitalization (mother, fetus and neonates). Antihypertensive drugs were used for blood pressure > or =160/110 mmHg, glucocorticoids for pregnancies of 24-34 weeks and magnesium sulfate for women with superimposed pre-eclampsia (SPE). The main outcome measures were fetal and neonatal deaths, fetal growth restriction (FGR), major neonatal complications and length of stay in the neonatal intensive care unit (NICU). RESULTS: Of 154 women studied, 78% developed SPE and the mean week's gestation at delivery was 34.5+/-4.6. The average birth weight was 2329+/-1011 g. and the FGR was 18.5%. Four patients had a dead fetus at the time of admission, eight during the hospitalization and there were six neonatal deaths resulting in perinatal mortality of 11.4%. Thirty-eight babies were admitted to the NICU, average stay was 14.8 days. The most common contributors to neonatal mortality and morbidity were pulmonary complications and sepsis. CONCLUSIONS: This study found that the neonatal outcomes in pregnancy with SCH are better than the historical experience, but preterm deliveries, cesarean section, SPE, abruptions and total perinatal mortality remains very high.     

Trends in the Occurrence of Antenatal and Perinatal Complications with Increasing Parity

Purpose

In modern days, grand multiparity is confined to communities where contraception is not practiced because of social and religious beliefs. For this reason, it is quite prevalent in all GCC countries. Few studies have compared the outcomes between the three groups: low parity (2–4), grand multiparity (5–9), and great grand multiparity (10 and more) . This study intended to analyze the trends in the occurrence of various perinatal complications across these three groups.

Methods

This historical cohort study was conducted in Mafraq Hospital, Abu Dhabi between January 1, 2009 and December 31, 2011. There were 1,658 multipara, 1,198 grand multipara, and 160 great grand multipara.

Results

Different complications revealed different trends with increasing parity. Many antenatal and intrapartum complications like diabetes (overt and gestational), anemia, preterm delivery, malpresentation at term, postpartum hemorrhage, and macrosomia showed a linear increase with increasing parity, while some, like the need for labor augmentation and soft tissue injuries showed a declining trend with increasing parity. Interestingly, some complications like placenta praevia, need for induction of labor, cesarean delivery, and post-term delivery followed an inverted V curve, showing an increase in their occurrence up to parity nine but a decline thereafter with further increasing parity of ten or beyond.

Conclusion

Women in different parity groups were at risk of different complications. There are some complications which decrease with increasing parity, and perinatal mortality remains very low suggesting that in modern settings, with favorable socioeconomic conditions and access to high-quality healthcare, a satisfactory perinatal outcome can be expected with low morbidity and mortality.     

Perinatal mortality in the Maltese Islands

This study analyzes the perinatal mortality statistics for the Maltese Islands since 1950 and compares them to those of other European countries. The mortality rate has taken a variable downward trend which can be correlated to important events during this period. Hospital perinatal mortality statistics are reviewed in the light of the national statistics.     

子(癎)前期患者蛋白尿程度与围生儿结局的研究

目的:探讨子癎前期患者蛋白尿程度对其围生儿结局的影响。方法:对287例住院分娩的子癎前期患者根据蛋白尿程度进行分组,分别回顾性研究其围生儿结局,比较不同程度蛋白尿患者围生儿结局的差异。结果:随患者蛋白尿的加重,分娩孕周提前,新生儿出生体重明显下降;剖宫产分娩和治疗性引产数升高,而自然分娩数减少;低体重儿发生率、围生儿死亡率、医源性早产率、收住NICU率均明显升高,但新生儿窒息发生率差异无显著性。将所有病例根据分娩孕周分为两组,≥32周分娩者其围生儿结局在不同程度蛋白尿患者各组之间差异显著,而32周之前分娩者其围生儿结局在不同程度蛋白尿之间差异无显著性。结论:随蛋白尿加重,围生儿结局恶化,但较早的早产儿中,孕龄过小是造成围生儿不良结局的另一不利因素,因而终止妊娠应适时。     

Hospitalization vs. outpatient care in the management of triplet gestations.

OBJECTIVE: To compare the course and outcome of triplet gestations under a preventive care strategy that includes hospitalization, surveillance, bed rest, and daily specialized care from the beginning of the second trimester, with pregnancies managed according to the Croatian standard outpatient care protocol for multiplets. METHODS: A retrospective study of 79 triplet pregnancies. Preventive hospitalization from the beginning of the second trimester, with complete bed rest and all necessary interventions, was chosen by 55 women (Group I). The remaining 24 women (Group II) elected the standard outpatient protocol for multiple pregnancies. Outpatient management with prophylactic bed rest was initiated at home as soon as the multiple pregnancy was diagnosed. After 28 weeks of gestation, all outpatients were hospitalized until delivery irrespective of symptoms. RESULTS: There was no difference between the groups regarding maternal age, race, pre-pregnancy weight and height, weight gain during the first 24 weeks of pregnancy, or the proportion of pregnancies achieved with assisted reproductive technology. Four out of 55 women (7.2%) from Group I and 4 out of 24 women (12.5%) from Group II had monochorionic triplet pregnancies (P=n.s.). Nulliparity was more frequent in Group I than in Group II (P=0.006). Elective cesarean delivery was significantly more frequent in Group I (46 out of 55 gestations, 72.7%) than in Group II (9 out of 24 gestations, 37.5%), P=0.024. Gestational age at delivery and mean birth weight were significantly higher in Group I than in Group II (P<0.001). Deliveries up to 28 weeks of pregnancy were infrequent in Group I (P=0.02). Thirty-three gestations in Group I (60%) and 6 (25%) in Group II had a duration of 33-36 weeks (P<0.001). Two out of 55 triplet gestations in Group I (3.6%) and 4 out of 24 in Group II (16.7%) ended in spontaneous abortion (P=0.053). The survival of the three triplets was more frequent in Group I than in Group II (P=0.048). For gestations reaching 24 weeks or more, the fetal and perinatal death rate was significantly lower in Group I (P<0.001). In Group I the intrauterine death rate for fetuses weighing 1500 g or less was also significantly lower (P=0.007), and the early neonatal death rate was almost half (15.8 vs. 28.9%, P=0.157). There were no differences in other pregnancy complications between the two groups except significantly more frequent preterm premature rupture of membranes and preterm labor requiring parenteral tocolysis in Group II (P=0.042 and 0.036, respectively), and significantly more frequent fetal growth retardation in Group I (P<0.001). CONCLUSION: Preventive hospitalization offers a better outcome for triplets even though prolonged hospitalization and all other procedures necessary to achieve optimal pregnancy outcome are also offered in the Croatian standard outpatient care protocol for multiplet pregnancies.     

Perinatal outcome and amniotic fluid index in the antepartum and intrapartum periods: A meta-analysis

OBJECTIVE: Our purpose was to perform a meta-analysis of studies on the risks of cesarean delivery for fetal distress, 5-minute Apgar score <7, and umbilical arterial pH <7.00 in patients with antepartum or intrapartum amniotic fluid index >5.0 or <5.0 cm. STUDY DESIGN: Using a MEDLINE search, we reviewed all studies published between 1987 and 1997 that correlated antepartum or intrapartum amniotic fluid index with adverse peripartum outcomes. The inclusion criteria were studies in English that associated at least one of the selected adverse outcomes with an amniotic fluid index of 5.0 cm. Contingency tables were constructed for each study, and relative risks and standard errors of their logs were calculated. Fixed-effects pooled relative risks were calculated for groups of studies that were homogeneous, whereas random-effects pooled relative risks were calculated for significantly heterogeneous groups of studies. RESULTS: Eighteen reports describing 10,551 patients met our inclusion criteria. An antepartum amniotic fluid index of 5.0 cm, is associated with an increased risk of cesarean delivery for fetal distress (pooled relative risk, 2.2; 95% confidence interval, 1.5-3.4) and an Apgar score of <7 at 5 minutes (pooled relative risk, 5.2; 95% confidence interval, 2.4-11.3). An intrapartum amniotic fluid index of 相似文献   

Translation and validation of the Perinatal Grief Scale in a sample of Greek women with perinatal loss during the 1st and 2nd trimester of pregnancy

Objective: To translate and validate the Perinatal Grief Scale (PGS) (short version) in a sample of Greek women with perinatal loss during the first and second trimester of pregnancy.

Methods: One hundred seventy-six women were approached a few hours after the loss. Along with the PGS, three more questionnaires were completed: the Edinburgh Postnatal Depression Scale (EPDS), the Hospital Anxiety and Depression Scale (HADS) and the State-Trait Anxiety Inventory (STAI), in order to assess the convergent validity of the PGS.

Results: Total sample mean age was 34.1 years (SD?=?5.2). Mean values and Cronbach’s alpha coefficients for PGS subscales exceeded the minimum reliability standard of 0.70. Mean score for “Active grief” was 31.47 (SD?=?9.31), for “Difficulty Coping” was 23.13 (SD?=?7.54) and for “Despair” was 21.07 (SD?=?7.07). By applying Pearson’s correlation coefficients, PGS subscales positively correlated with scores on EPDS, STAI and HADS.

Conclusions: The PGS Greek version is a reliable instrument in terms of internal consistency and the Cronbach’s alpha coefficients are high. The Greek version of PGS can be a useful instrument for the detection of the psychological impact after a perinatal loss and it has implications for both scientific research and clinical routine.     

Continuous Abnormal Fetal Breathing in the Human Fetus Associated with Severe Perinatal Asphyxia

We present a case of continuous abnormal fetal breathing which was associated with a severely asphyxiated neonate. The period of apnea was fixed at approximately 3 s and the breathing activity consisted of a single inspiratory and expiratory movement. The depth of each breath appeared similar. No movement or tone was observed. This “picket fence” fetal breathing pattern, which has been described in fetal lambs as a preterminal event, has not been reported previously in humans.     

Impact of ALSO training on the management of prolonged labor and neonatal care at Kagera Regional Hospital, Tanzania

Objective

To evaluate the management of prolonged labor and neonatal care before and after Advanced Life Support in Obstetrics (ALSO) training.

Methods

Staff involved in childbirth at Kagera Regional Hospital, Tanzania, attended a 2-day ALSO provider course. In this prospective intervention study conducted between July and November 2008, the management and outcomes of 558 deliveries before and 550 after the training were observed.

Results

There was no significant difference in the rate of cesarean deliveries owing to prolonged labor, and vacuum delivery was not practiced after the intervention. During prolonged labor, action was delayed for more than 3 hours in half of the cases. The stillbirth rate, Apgar scores, and frequency of neonatal resuscitation did not change significantly. After the intervention, there was a significant increase in newborns given to their mothers within 10 minutes, from 5.6% to 71.5% (RR 12.71; 95% CI, 9.04-17.88). There was a significant decrease from 6 to 0 neonatal deaths before discharge among those born with an Apgar score after 1 minute of 4 or more (P = 0.03).

Conclusion

ALSO training had no effect on the management of prolonged labor. Early contact between newborn and mother was more frequently practiced after ALSO training and the immediate neonatal mortality decreased.     

Expected to deliver: Alignment of regulation, training, and actual performance of emergency obstetric care providers in Malawi and Tanzania

Objective

Policy, regulation, training, and support for cadres adopting tasks and roles outside their historical domain have lagged behind the practical shift in service-delivery on the ground. The Health Systems Strengthening for Equity (HSSE) project sought to assess the alignment between national policy and regulation, preservice training, district level expectations, and clinical practice of cadres providing some or all components of emergency obstetric care (EmOC) in Malawi and Tanzania.

Methods

A mixed methods approach was used, including key informant interviews, a survey of District Health Management Teams, and a survey of health providers employed at a representative sample of health facilities.

Results

A lack of alignment between national policy and regulation, training, and clinical practice was observed in both countries, particularly for cadres with less preservice training; a closer alignment was found between district level expectations and reported clinical practice. There is ineffective use of cadres that are trained and authorized to provide EmOC, but who are not delivering care, especially assisted vaginal delivery.

Conclusion

Better alignment between policy and practice, and support and training, and more efficient utilization of clinical staff are needed to achieve the quality health care for which the Malawian and Tanzanian health ministries and governments are accountable.