Perinatal Mortality and Associated Risk Factors: A Case Control Study

Background

Perinatal mortality is reported to be five times higher in developing than in developed nations. Little is known about the commonly associated risk factors for perinatal mortality in Southern Nations National Regional State of Ethiopia.

Methods

A case control study for perinatal mortality was conducted in University hospital between 2008 and 2010. Cases were stillbirths and early neonatal deaths. Controls were those live newborns till discharged from the hospital. Subgroup binary logistic regression analyses were done to identify associated risk factors for perinatal mortality, stillbirths and early neonatal deaths.

Results

A total of 1356 newborns (452 cases and 904 controls) were included in this analysis. The adjusted perinatal mortality rate was 85/1000 total delivery. Stillbirths accounted for 87% of total perinatal mortality. The proportion of hospital perinatal deaths was 26%. Obstructed labor was responsible for more than one third of perinatal deaths. Adjusted odds ratios revealed that obstructed labor, malpresentation, preterm birth, antepartum hemmorrhage and hypertensive disorders of pregnancy were independent predictors for high perinatal mortality. In the subgroup analysis, among others, obstructed labor and antepartum hemorrhage found to have independent association with both stillbirths and early neonatal deaths.

Conclusion

The perinatal mortality rate was more than two fold higher than the estimated national perinatal mortality;and obstructed labor, malpresentation, preterm birth, antepartum hemmorrhage and hypertensive disorders of pregnancy were independent predictors. The reason for the poor progress of labor and developing obstructed labor is an area of further investigation.     

Risk factors for perinatal deaths in rural Bangladesh

Perinatal mortality refers to stillbirths and deaths which occur during the first week of life. 7 million such deaths occur annually worldwide, almost all of which are in developing countries. Rates as high as 75-100 deaths/1000 births have been documented in developing countries. The 3 leading causes of perinatal mortality are complications of pre-term birth, birth asphyxia and birth trauma, and bacterial infections. The other causes of perinatal mortality are largely unknown due to difficulties in documenting stillbirths in developing countries. In many developing country societies, it is culturally unacceptable to acknowledge a birth until it has survived its first week of life. This study identified and quantified the risk factors for perinatal deaths in a rural community in Manikganj district, Bangladesh. Cases were mothers whose infants died in the perinatal period, while comparison mothers were those whose infants survived the perinatal period. Of the 186 infant deaths recorded, 130 (69.9%) were in the perinatal period, and included 53 stillbirths. The perinatal death rate was 64.5/1000 births. Logistic regression confirmed that maternal age, parity, and mal-presentation were significantly associated with perinatal deaths. Mal-presentation was independently associated with a increased risk of perinatal death.     

Demographic survey of the level and determinants of perinatal mortality in Karachi, Pakistan

Summary. .A demographic survey was used to estimate the level and determinants of perinatal mortality in eight lower socio-economic squatter settlements of Karachi, Pakistan. The perinatal mortality rate was 54.1 per 1000 births, with a stillbirth to early neonatal mortality ratio of 1:1. About 65% of neonatal deaths occurred in the early neonatal period, and early neonatal mortality contributed 32% of all infant deaths. Risk factor assessment was conducted on 375 perinatal deaths and 6070 current survivors. Poorer socio-economic status variables such as maternal and paternal illiteracy, maternal work outside the home and fewer household assets were significantly associated with perinatal mortality as were biological factors of higher parental age, short birth intervals and poor obstetric history. Multivariable logistic analysis indicated that some socioeconomic factors retained their significance after adjusting for the more proximate biological factors. Population attributable risk estimates suggest that public health measures for screening of high-risk women and use of family planning to space births will not improve perinatal mortality substantially without improvement of socio-economic conditions, particularly maternal education. The results of this study indicate that an evaluation of perinatal mortality can be conducted using pregnancy histories derived from demographic surveys.     

Analysis of perinatal mortality and its components: time for a change?

Since the midtwentieth century, stillbirths (late fetal deaths) and early neonatal deaths have often been combined into a single category of "perinatal" deaths. In the past, such a combination was justified by the fact that asphyxia was a common cause of death during labor (intrapartum stillbirth) and shortly after birth and by geographic and temporal differences in classification of livebirths versus stillbirths. In more recent years, however, the etiologic determinants have diverged sharply, with many fewer early neonatal deaths caused by asphyxia and relatively many more caused by congenital anomalies. Moreover, the increasingly common stratification of pregnancy outcome measures by gestational age or birth weight leads to the use of an inappropriate denominator (total livebirths plus stillbirths within each gestational age or birth weight category) for denoting risk for the stillbirth component, because all unborn fetuses (including the majority of those not born within the specified gestational age or birth weight range) are at risk of being stillborn in that range. The authors suggest that, whenever possible, stillbirths and early neonatal deaths should be reported separately, with gestational age-specific risks of stillbirth based on all fetuses at risk, and that antepartum and intrapartum stillbirths be reported separately.     

La mortalité périnatale : ampleur et causes à Lubumbashi,République démocratique du Congo

BackgroundThe present study was initiated in order to determine the rate, the causes and the risk factors for perinatal mortality in Lubumbashi, Democratic Republic of Congo.MethodsData for this cross-sectional study were collected by interviewing participating women and by analysis of medical files. Women who gave birth in 2010 and were residents of Lubumbashi during the same year were included. Women were included irrespective of the pregnancy outcome and perinatal survival was determined for newborns aged at least seven days. Women were recruited from households selected by cluster sampling for healthcare zones. Perinatal mortality was defined as stillbirths and early neonatal deaths per 1000 births. Risk factors were sought using the odds ratio method adjusted by logistic regression using a 5% threshold.ResultsAmong 11,536 surveyed women, there were 11,633 births including 177 stillbirths and 133 early neonatal deaths. Perinatal mortality was 27‰ (95%IC = 23.7–29.6‰). The causes of this mortality were respiratory distress (58.2%), neonatal infection (pneumonia and neonatal meningitis, 13.5%), complications of prematurity (9.0%), neonatal tetanus (1.6%), congenital malformations (0.6%). The cause of perinatal death was unknown for 17.1%. Risk factors for perinatal mortality were: unmarried mother; home delivery; complicated delivery; dystocia; caesarean-section; multiple pregnancy; low birth weight; prematurity.ConclusionAction should be taken to improve availability, use and quality of Emergency obstetrical and neonatal care. Women should be better informed concerning the danger signs of pregnancy and childbirth.     

Evaluation of antenatal risk scoring in a preterm birth prevention and perinatal loss

The study aim was to determine risk factors associated with preterm delivery, perinatal mortality, and neonatal morbidity among 687 indigent, pregnant women in their first term registered with the New Civil Hospital, Ahmedabad, India, between September, 1989, and March, 1991. Women were scored according to their level of risk: no risk, mild risk, moderate risk, and severe risk, from scores based on sociodemographic and obstetric data: pallor, maternal weight, 2 or more prior abortions, first pregnancy or 5 pregnancies, adolescent pregnancy, prior preterm birth, prior prenatal mortality or stillbirths. Out of 696 deliveries, there were 71 (10.2%) preterm births, of which 3 (2.38%) were among women within the no risk groups. There were 47 (11.10%) from the mild risk group and 20 (14.08%) from the moderate risk group. There were 20% from the severe risk group. Perinatal mortality was 84.77/1000 births, and 7.94 among the no risk group. The perinatal mortality rate rose with level of risk, with 92.20 per thousand births for the mild risks to 200 for the severe risks, which was statistically significant. Neonatal morbidity also increased with the increased level of risk. Preterm birth was found not to be associated with pallor and prior history of stillbirth. Perinatal mortality was not associated with pallor and first pregnancy. Factors significantly associated with preterm births and perinatal mortality were maternal malnutrition, higher pregnancy order, older maternal age at delivery, and prior preterm births and fetal loss. Pregnant women with risk factors had greater relative risk of preterm birth and perinatal mortality by 5.01 and 13.09 times. With maternal risk factors, the risk increased by 80.05% and 92.35%. The risk factors were highly sensitive for preterm births (95.77%), but had low specificity (19.69%), and low positive predictive value (11.93%). Perinatal mortality sensitivity, specificity, and positive predictive values were 98.31%, 19.90%, and 10.34%n respectively. The findings differed from previously reported studies; scoring system used has a higher sensitivity to predicting preterm birth and perinatal mortality among high risk women, and poor sensitivity among low risk women. Moderate and mild could be identified with this system and referred for follow-up.     

An assessment of the effects of maternal age and parity in different components of perinatal mortality

Perinatal mortality has several components which may have distinct epidemiologic features. In an investigation of the total singleton birth population of New York City in 1976-1978 (n = 320,726), the authors divided perinatal mortality into four components: late fetal deaths that occurred before labor (late antepartum fetal deaths), fetal deaths during labor (intrapartum fetal deaths), neonatal deaths, and perinatal deaths attributed to congenital anomalies, and they assessed the relation of each of these to maternal age and parity, controlling for relevant confounding factors. In analyses which controlled for prior fetal loss, type of service (public vs. private), race, marital status, and mother's educational attainment in a multiple logistic regression model, the authors found that: 1) increasing maternal age was strongly associated with antepartum fetal deaths but not with intrapartum fetal deaths, while older maternal age was also associated with perinatal deaths attributed to congenital anomalies; 2) high parity bore a strong relationship to intrapartum fetal deaths, but none to antepartum fetal deaths, neonatal deaths, or congenital anomaly deaths; and 3) for neonatal death, there was a statistically significant (p less than 0.001) interaction between parity and age such that mothers over 34 years old having their first birth were at especially high risk.     

A Case Series Study of Perinatal Deaths at One Referral Center in Rural Post-conflict Liberia

The overall objective of this study was to further our understanding of the factors contributing to the high perinatal mortality rates at a busy rural, referral hospital in Liberia. The specific aims were to: (1) analyze the records of women who experienced a perinatal loss for both medical and nonmedical contributing factors; (2) describe the timing and causes of all documented stillbirths and early neonatal deaths; and (3) understand the factors surrounding stillbirth and early neonatal death in this context. This case series study was conducted through a retrospective hospital-based record review of all perinatal deaths occurring at the largest rural referral hospital in north-central Liberia during the 2010 calendar year. A record review of 1,656 deliveries identified 196 perinatal deaths; 143 classified as stillbirth and 53 were classified as early neonatal death. The majority of stillbirths (56.6 %) presented as antenatal stillbirths with no fetal heart tones documented upon admission. Thirty-one percent of cases had no maternal or obstetrical diagnosis recorded in the chart when a stillbirth occurred. Of the 53 early neonatal deaths, 47.2 % occurred on day one of the infant’s life with birth asphyxia/poor Apgar scores being the diagnosis listed most frequently. Clear and concise documentation is key to understanding the high perinatal death rates in low resource countries. Standardized, detailed documentation is needed to inform changes to clinical practice and develop feasible solutions to reduce the number of perinatal deaths worldwide.     

Influence of prenatal diagnosis and pregnancy termination of fetuses with birth defects on the perinatal mortality rate in Victoria, Australia

Historical data show that in Victoria birth defects have accounted for approximately 25% of all perinatal deaths. Terminations of pregnancies (TOPs) for birth defects occurring at > or =20 weeks gestation are included in the population-based perinatal data collection. These are classified as stillbirths or neonatal deaths. Some would have survived the perinatal period if no termination had taken place, and as a result they have the effect of increasing the perinatal mortality rate (PMR). Conversely, TOPs <20 weeks gestation, of fetuses with lethal birth defects that would have resulted in a perinatal death, are not included in the statistics and therefore reduce the PMR. The aim of this study was to examine the effect on the PMR of TOPs following the prenatal detection of birth defects, taking into account the severity or 'lethality' of the birth defects. Data on live births, stillbirths, neonatal deaths and TOPs carried out because of a birth defect were collected from the Victorian Birth Defects Register (BDR) for 1989-2000. Birth defects were categorised into three groups, according to the estimated likelihood of a baby with that condition dying in the perinatal period: a 'lethal' birth defect was one where there was >50% likelihood of death, 'possibly lethal' 15-50% and 'non-lethal' less than 15%. Based on these 'lethality' groups and associated assumptions about average survival rates beyond the neonatal period, the PMR was recalculated. TOPs for 'non-lethal' birth defects at > or =20 weeks gestation increased the PMR by 3.8%. TOPs for 'lethal' birth defects <20 weeks decreased the PMR by 14.4%. The net effect on the overall PMR from TOPs for birth defects was a 10.6% decrease.     

Risk of teen-age pregnancy in a rural community of India

In India, there has been a declining trend in teenage pregnancy between 1977-79 and 1981-84. Teenage pregnancy tends to occur within marriages, often arranged by parents, and few pregnancies occur among unmarried teenagers. There are nevertheless concerns about the higher rates of nutritional and obstetric problems associated with adolescent pregnancy and the ignorance and immaturity which can result in higher morbidity and mortality among mothers and babies. The change to a minimum age of 18 years for marriage has been suggested as a means of reducing the number of adolescent pregnancies. The study sample included 5994 deliveries in the rural health district area of Sirur, Maharashtra state, India, between 1981 and 1984. Adolescent pregnancies (to women under 20 years old) amounted to 598 deliveries, or 10% of deliveries. The perinatal mortality rate among teenage first births to high-risk mothers (238) under 18 years old was 67.2 per 100 births; the neonatal mortality rate was 61.4. Risk factors such as prolonged labor, short stature, and anemia were associated more with women under 18 years old. Statistically significant differences were found in the rate of low birth weight infants, stillbirths, and late neonatal deaths among women aged under 18 years compared to other women. The perinatal mortality rate was 7-16 times greater when associated risk factors, except anemia, were present. The neonatal mortality rate was 2.5-18 times greater when associated risk factors, except anemia and edema, were present. Late neonatal mortality was 2.2 times higher among infants with mothers under 18 years old. Recommendations were to provide general health education about risks of teenage pregnancy, strictly enforce the minimum age at marriage law, screen all pregnant mothers for risk factors, and provide at-risk mothers with education about child bearing and rearing and referral to a hospital for safe delivery. Referrals are particularly important among first pregnancies among women under 18 years old with multiple risk factors.     

Rates, timing and causes of neonatal deaths in rural India: implications for neonatal health programmes

OBJECTIVE: To assess the rates, timing and causes of neonatal deaths and the burden of stillbirths in rural Uttar Pradesh, India. We discuss the implications of our findings for neonatal interventions. METHODS: We used verbal autopsy interviews to investigate 1048 neonatal deaths and stillbirths. FINDINGS: There were 430 stillbirths reported, comprising 41% of all deaths in the sample. Of the 618 live births, 32% deaths were on the day of birth, 50% occurred during the first 3 days of life and 71% were during the first week. The primary causes of death on the first day of life (i.e. day 0) were birth asphyxia or injury (31%) and preterm birth (26%). During days 1-6, the most frequent causes of death were preterm birth (30%) and sepsis or pneumonia (25%). Half of all deaths caused by sepsis or pneumonia occurred during the first week of life. The proportion of deaths attributed to sepsis or pneumonia increased to 45% and 36% during days 7-13 and 14-27, respectively. CONCLUSION: Stillbirths and deaths on the day of birth represent a large proportion of perinatal and neonatal deaths, highlighting an urgent need to improve coverage with skilled birth attendants and to ensure access to emergency obstetric care. Health interventions to improve essential neonatal care and care-seeking behavior are also needed, particularly for preterm neonates in the early postnatal period.     

Prospective community-based cluster census and case-control study of stillbirths and neonatal deaths in the West Bank and Gaza Strip

Obstetric complications and newborn illnesses amenable to basic medical interventions underlie most perinatal deaths. Yet, despite good access to maternal and newborn care in many transitional countries, perinatal mortality is often not monitored in these settings. The present study identified risk factors for perinatal death and the level and causes of stillbirths and neonatal deaths in the West Bank and Gaza Strip. Baseline and follow-up censuses with prospective monitoring of pregnant women and newborns from September 2001 to August 2002 were conducted in 83 randomly selected clusters of 300 households each. A total of 113 of 116 married women 15-49 years old with a stillbirth or neonatal death and 813 randomly selected women with a surviving neonate were interviewed, and obstetric and newborn care records of women with a stillbirth or neonatal death were abstracted. The perinatal and neonatal mortality rates, respectively, were 21.2 [95% confidence interval (CI) 16.5, 25.9] and 14.7 [95% CI 10.2, 19.2] per 1000 livebirths. The most common cause (27%) of 96 perinatal deaths was asphyxia alone (21) or with neonatal sepsis (5), while 18/49 (37%) early and 9/19 (47%) late neonatal deaths were from respiratory distress syndrome (12) or sepsis (9) alone or together (6). Constraint in care seeking, mainly by an Israeli checkpoint, occurred in 8% and 10%, respectively, of 112 pregnancies and labours and 31% of 16 neonates prior to perinatal or late neonatal death. Poor quality care for a complication associated with the death was identified among 40% and 20%, respectively, of 112 pregnancies and labour/deliveries and 43% of 68 neonates. (Correction added after online publication 5 June 2008: The denominators 112 pregnancies, labours, and labour/deliveries, and 16 and 68 neonates were included; and 9% of labours was corrected to 10%.) Risk factors for perinatal death as assessed by multivariable logistic regression included preterm delivery (odds ratio [OR] = 11.9, [95% CI 6.7, 21.2]), antepartum haemorrhage (OR = 5.6, [95% CI 1.5, 20.9]), any severe pregnancy complication (OR = 3.4, [95% CI 1.8, 6.6]), term delivery in a government hospital and having a labour and delivery complication (OR = 3.8, [95% CI 1.2, 12.0]), more than one delivery complication (OR = 4.4, [95% CI 1.8, 10.5]), mother's age >35 years (OR = 2.9, [95% CI 1.3, 6.8]) and primiparity in a full-term pregnancy (OR = 2.6, [1.1, 6.3]). Stillbirths are not officially reportable in the West Bank and Gaza Strip and this is the first time that perinatal mortality has been examined. Interventions to lower stillbirths and neonatal deaths should focus on improving the quality of medical care for important obstetric complications and newborn illnesses. Other transitional countries can draw lessons for their health care systems from these findings.     

中国3省市21家医院早产发生的相关因素及结局研究

目的 分析早产发生的影响因素与结局,为早产的防治工作提供依据. 方法 对3省市21家医院完成分娩的全部产妇13 322例进行调查,计算早产发生率,分析早产发生的相关因素,比较早产儿与足月儿的新生儿结局. 结果 早产发生率为6.0％,其中晚期早产（孕周34～36周）占77.3％;导致早产发生危险增加的因素有年龄＜20岁、年龄＞35岁、在校读书年数＞12年、多胎、发生妊娠合并症;早产导致死胎或死产,低、极低出生体重,Apgar得分≤7分,进入新生儿重症监护室,出院前或生后7d内死亡的危险增加. 结论 早产是威胁胎儿及新生儿健康的重要因素,应尽早识别具备早产危险因素的孕妇,以便及时开展针对性的治疗工作.     

Ethnic differences in perinatal mortality--a challenge.

The perinatal mortality rates of mothers who delivered at St. Thomas's Hospital from 1969 to 1976 have been examined. The rate in the West Indian population was significant higher than in the United Kingdom white population. The increased West Indian mortality was confined to infants with a birth weight of more than 2.0 kg and a gestational age of more than 37 weeks. The relative risk of perinatal death for West Indian mothers compared with UK white mothers was 1.4 at birth weights of 2.5 kg to 2.9 kg, rising to 4.3 at 4.0 + kg. West Indian perinatal mortality in term babies of normal birth weight was higher in all maternal age and parity groups except parity 3, but the difference was greatest in women aged 30 or over. The African perinatal mortality rate was not significantly greater than the UK white rate although it followed the West Indian trends. Pre-eclampsia and forceps delivery were associated with a greatly increased perinatal mortality in West Indian babies. The excess West Indian mortality could not be explained completely by differences in the proportions of stillbirths and early neonatal deaths nor by the distribution of births by parity, maternal age, or social class. Possible explanations for the differences in mortality are discussed.     

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.     

In utero exposure to steroid contraceptives and survival during infancy.

A cohort study was conducted in Chiang Mai, northern Thailand, in 1,431 children of women who had used the injectable contraceptive Depo-Provera (The Upjohn Company, Kalamazoo, Michigan), 565 children of women who had used oral contraceptives during pregnancy, and a group of 2,307 control infants with no hormonal contraceptive exposures. In follow-up interviews, information was obtained on stillbirths and deaths. Cause of death was ascertained by interview, death certificate, or medical record, and underlying causes of death were ascribed by a panel. The children exposed in utero to Depo-Provera had higher neonatal and infant mortality rates (44.3 and 62.9 per 1,000 live births, respectively) than did the controls (19.8 and 29.1 per 1,000 live births). Mortality in infants exposed in utero to oral contraceptives was intermediate between that in the other two groups. Adjustment by logistic regression showed no significantly increased risk of mortality among infants exposed to oral contraceptives, but the odds ratio for death was significantly increased with Depo-Provera exposures due to accidental pregnancy (odds ratio (OR) = 1.8 (95% confidence interval (Cl) 1.1-3.0) for neonatal deaths; OR = 2.0 (95% Cl 1.3-3.2) for infant deaths). Adjustment for low birth weight reduced the risks, suggesting that low birth weight may act as an intermediate determinant of Depo-Provera-associated mortality. Among the accidental pregnancies with Depo-Provera, there was a relation between shorter injection-to-conception intervals, when maternal blood levels of the drug are high, and an increased risk of mortality. The odds ratios for neonatal mortality were 2.5 (95% Cl 1.1-5.7), 2.1 (95% Cl 1.0-4.6), and 0.9 (95% Cl 0.4-2.4) for injection-to-conception intervals of less than or equal to 4, 5-8, and greater than 9 weeks, respectively. Adjustment for low birth weight reduced these risks. Chi-square tests for trend were highly significant. Similar associations were also observed between Depo-Provera accidental pregnancies and risks of low birth weight. Thus, infants from accidental pregnancies that occur 1-2 months after a 150-mg Depo-Provera injection may be at increased risk for low birth weight and death. However, the attributable risk is low, because such pregnancies are uncommon.     

Stillbirths and neonatal encephalopathy in Kathmandu, Nepal: an estimate of the contribution of birth asphyxia to perinatal mortality in a low-income urban population

We describe a prospective cross-sectional survey over a 12-month period in the principal maternity hospital of Kathmandu, Nepal, where over 50% of the local population deliver. The study aim was to estimate the contribution of birth asphyxia to perinatal mortality in this setting. During 1995, there were 14,371 livebirths and 400 stillbirths, a total stillbirth rate of 27 per 1000 total births. The fresh term (2000 g or more) stillbirth rate was 8.5 per 1000 total births [95% CI 7.1, 10.1]. Ninety-two cases of neonatal encephalopathy (NE) affecting term infants were detected (excluding those due to congenital malformations, hypoglycaemia and early neonatal sepsis). The birth prevalence of NE was 6.4 per 1000 livebirths [95% CI 5.2, 7.8]. There was evidence of intrapartum compromise in 63 (68%) of the cases of NE and 65 (76%) of the stillbirths, but only in 12 (12%) of controls. The cause-specific early neonatal mortality rate for NE was 2.1 per 1000 livebirths [95% CI 1.4, 3.0]. Combining the NE deaths and fresh stillbirths gives an upper estimate for term birth asphyxia perinatal mortality rate of 10.8 per 1000 total births [95% CI 9.2, 12.6], 24% of all perinatal deaths before hospital discharge. This study suggests that birth asphyxia remains an important cause of perinatal mortality in developing countries. The paper discusses the pros and cons of different strategies to reduce birth asphyxia in low-income countries.     

Cause-Specific Stillbirth and Neonatal Death According to Prepregnancy Obesity and Early Gestational Weight Gain: A Study in the Danish National Birth Cohort

Maternal obesity is associated with impaired fetal and neonatal survival, but underlying mechanisms are poorly understood. We examined how prepregnancy BMI and early gestational weight gain (GWG) were associated with cause-specific stillbirth and neonatal death. In 85,822 pregnancies in the Danish National Birth Cohort (1996–2002), we identified causes of death from medical records for 272 late stillbirths and 228 neonatal deaths. Prepregnancy BMI and early GWG derived from an early pregnancy interview and Cox regression were used to estimate associations with stillbirth or neonatal death as a combined outcome and nine specific cause-of-death categories. Compared to women with normal weight, risk of stillbirth or neonatal death was increased by 66% with overweight and 78% with obesity. Especially deaths due to placental dysfunction, umbilical cord complications, intrapartum events, and infections were increased in women with obesity. More stillbirths and neonatal deaths were observed in women with BMI < 25 and low GWG. Additionally, unexplained intrauterine death was increased with low GWG, while more early stillbirths were seen with both low and high GWG. In conclusion, causes of death that relate to vascular and metabolic disturbances were increased in women with obesity. Low early GWG in women of normal weight deserves more clinical attention.     

Risk of stillbirth from occupational and residential exposures.

OBJECTIVES: To analyse the risk of stillbirth from 12 residential and occupational maternal exposures during pregnancy. METHODS: Stillbirths and neonatal deaths in 1984 within 24 hours of birth from 10 California counties were identified from death certificates. Controls were randomly selected from live births born in 1984 and frequency matched to cases by maternal age and county. Data sources included vital statistics and a self-administered postal questionnaire. Logistic regression and proportional hazards modelling were performed; the proportional hazards considered the truncated opportunity for exposure among cases. Special focus was given to two cause of deaths groups: congenital anomalies (12% of deaths) and complications of the placenta, cord, and membranes (37% of deaths). RESULTS: Occupational exposure to pesticides during the first two months of gestation was positively associated with stillbirths due to congenital anomalies (odds ratio (OR) 2.4, 95% confidence interval (95% CI) 1.0 to 5.9), and during the first and second trimesters with stillbirths due to all causes of death (risk ratios (RR) 1.3-1.4, 95% CI 1.0 to 1.7) and stillbirths due to complications of the placenta, cord, and membranes (RR 1.6-1.7, 95% CI 1.1 to 2.3). Occupational exposure to video display terminals in the third trimester was found to have a modest inverse association with stillbirths (RR 0.7, 95% CI 0.6, 0.9). Home pesticide exposure was positively associated with stillbirths due to congenital anomalies (OR 1.7, 95% CI 1.0 to 2.9). CONCLUSIONS: Occupational exposure to pesticides, especially during early pregnancy, had a clear positive association with stillbirths regardless of cause of death. Methodologically, this study of stillbirths is unique in its analysis of specific causes of death and use of time specific exposure windows.     

Aetiology of stillbirths and neonatal deaths in rural Ghana: implications for health programming in developing countries

In developing countries many stillbirths and neonatal deaths occur at home and cause of death is not recorded by national health information systems. A community-level verbal autopsy tool was used to obtain data on the aetiology of stillbirths and neonatal deaths in rural Ghana. Objectives were to describe the timing and distribution of causes of stillbirths and neonatal deaths according to site of death (health facility or home). Data were collected from 1 January 2003 to 30 June 2004; 20 317 deliveries, 696 stillbirths and 623 neonatal deaths occurred over that time.
Most deaths occurred in the antepartum period (28 weeks gestation to the onset of labour) (33.0%). However, the highest risk periods were during labour and delivery (intrapartum period) and the first day of life. Infections were a major cause of death in the antepartum (10.1%) and neonatal (40.3%) periods. The most important cause of intrapartum death was obstetric complications (59.3%). There were significantly fewer neonatal deaths resulting from birth asphyxia in the home than in the health facilities and more deaths from infection. Only 59 (20.7%) mothers of neonates who died at home reported that they sought care from an appropriate health care provider (doctor, nurse or health facility) during their baby's illness. The results from this study highlight the importance of studying community-level data in developing countries and the high risk of intrapartum stillbirths and infectious diseases in the rural African mother and neonate. Community-level interventions are urgently needed, especially interventions that reduce intrapartum deaths and infection rates in the mother and infant.