Total perinatal wastage. A clarification of priorities

Summary. The pregrmncy outcome of 16 971 women carrying 17 352 living fetuses after 16 weeks gestation was studied. As well as recording perinatal deaths, all losses before 28 weeks and up to one year after delivery were recorded to give a total perinatal wastage rate of 21.6 per 1000 fetuses alive at 16 weeks compared with a perinatal mortality rate (stillbirths plus early neonatal deaths) of 7.8 per 1000 births. All deaths were then classified according to pathological sub-groups. The concept of auditing perinatal care using perinatal mortality was then compared with that using total perinatal wastage.     

The impact of multiple pregnancies and malformations on perinatal mortality

AIM: To evaluate the impact of the rate of multiple pregnancies and congenital malformations on perinatal mortality. METHODS: The study is based on data from the perinatal audit in Vejle County Denmark. Fetal deaths with gestational age > or = 22 weeks and deaths in livebirths within the first 28 days after birth were included in the calculated perinatal mortality. Total number of births was 30,181 and 252 pregnancies and 268 fetuses/infants were evaluated. The study period was 1995-2000. There was no routine ultrasound screening for congenital malformations in the county, though midtrimester ultrasound was used to assess gestational age. RESULTS: Perinatal mortality was 8.9 per 1000 births with no significant change over time. Rate of multiple pregnancies was 1.94% ranging from 1.81% during the first 3 years to 2.06% for the last 3 years (not significant). Fetuses and infants from multiple pregnancies contributed 18% of all deaths. Perinatal mortality for single births was 7.6 per 1000 births and for multiple births 42.2/1000 (P<0.0001). The distribution of gestational age for single and multiple births was highly significant (P<0.0001) with 67% of multiple pregnancies with GA < 28 weeks compared to 26% of single pregnancies. Nineteen percent of all deaths were caused by congenital malformations and the majority of these were potentially detectable by ultrasound investigation. CONCLUSIONS: The increasing rate of multiple pregnancies makes it difficult to see improvements in perinatal mortality. Calculated from the perinatal mortality in single and multiple pregnancies in Vejle County assisted conceptions contribute with an an excess of 45 perinatal deaths per year in Denmark. The difference between countries in rate of multiple pregnancies and in prenatal ultrasound screening recommendations for malformations makes it difficult to compare perinatal mortality.     

Fetal assessment based on fetal biophysical profile scoring: experience in 12,620 referred high-risk pregnancies. I. Perinatal mortality by frequency and etiology

Fetal biophysical profile scoring was used as a method for antepartum fetal risk assessment in 12,620 high-risk patients referred in a 55-month interval. A total of 26,257 tests were performed on these patients (range, one to 18 tests per patient). Ninety-three perinatal deaths occurred (gross perinatal mortality rate, 7.37 per 1000) of which 62 (66.6%) were due to a major anomaly, seven were due to Rh disease (7.5%), and the remaining 24 deaths (25.8%) occurred in structurally normal fetuses. The corrected perinatal mortality rate was 1.90 per 1000. Eight structurally normal fetuses died within 1 week of a normal test result (corrected false negative rate, 0.634 per 1000). These data suggest fetal biophysical profile scoring is an accurate method for identification of the fetus at risk for perinatal death.     

Outcome of twin deliveries at the University Teaching Hospital, Yaoundé, Cameroon-a 15-year experience.

From 1982 to 1996, a total of 16 181 deliveries was registered at the obstetric unit of the Yaoundé University, Cameroon, out of which 291 were twins (1.8%). For the latter, the average gestational age was 37 +/- 2.9 weeks. In 45.0% of cases both fetuses presented cephalic, in 42.6% one presented cephalic and the other breech, while both fetuses presented as breech in 9.9% of cases. The frequency of the combination cephalic-transverse was 0.05%. Spontaneous delivery of both babies was observed in 90.2% of the patients, while in 9.7% delivery of both babies was by caesarian section. The caesarian section rate for a retained second twin was 1%. The perinatal mortality rate was 65 per 1000 (38 deaths in the first week of life), out of which the fetal loss was 4.4% for the first twin compared with 7.9% for the second. The perinatal mortality for the second twin was significantly associated with the type of fetal presentation at the time of delivery, as well as the time gap between the delivery of the twins. Sixteen deaths were observed amongst second twins after podalic presentation out of a total of 23 deaths recorded in the group. In addition, the mortality rate among second twins born more than 20 minutes after expulsion of the first was four times higher than in those delivered within 20 minutes time interval (16.0%5 versus 4.3%). The main cause of twin deaths in our study was found to be prematurity which complicated 30 cases of the registered deaths (78.9%).     

Perinatal mortality in first- and second-born twins in the United States

OBJECTIVE: To evaluate the prevailing mortality paradox that second-born twins are at higher risk of perinatal mortality than first-born twins. METHODS: We used the 1995-1997 United States "matched multiple birth" data files assembled by the National Center for Health Statistics, for analysis of risk of perinatal mortality in first- and second-born twins (293788 fetuses). Perinatal mortality was defined to include stillbirths after 20 weeks of gestation and neonatal deaths (deaths within the first 28 days). Gestational age-specific risk of perinatal mortality (per 1000 total births), stillbirth (per 1000 total births), and neonatal mortality (per 1000 livebirths) by order of twin birth were based on the fetuses-at-risk approach. Associations between order of birth and mortality indices were evaluated by fitting multivariable logistic regression models based on the method of generalized estimating equations. These models were adjusted for several potential confounding factors. RESULTS: Perinatal mortality was 37% higher in second-born (26.1 per 1000 total births) than in first-born (20.3 per 1000 total births) twins (adjusted relative risk [RR] 1.37; 95% confidence interval [CI] 1.32, 1.42). The increased risk of perinatal mortality in second-born twins was chiefly driven by a 2.46-fold (95% CI 2.29, 2.63) increase in the number of stillbirths. However, the risk of neonatal mortality was very similar between first- and second-born twins (RR 0.99, 95% CI 0.95, 1.04). CONCLUSIONS: The increased risk of perinatal death in second-born twins is driven chiefly by increased rates of stillborn second twins. Thus, the increased mortality in second-born over first-born twins probably is an artifact of mortality comparisons.     

Perinatally related wastage--a proposed classification of primary obstetric factors

Adapting Sir Dugald Baird's concept of primary obstetric causes of perinatal mortality, a revised clinico-pathological classification has been evolved to take account of new knowledge and developments, and to direct attention to potentially avoidable deaths and to where intensified efforts and investigation are needed. Categories highlighting the importance of intrauterine growth retardation, unexplained intrauterine death and spontaneous premature labour have been introduced, intrapartum hypoxia is separated from birth trauma, and infection again has its own category. Regular perinatal audit at one obstetric hospital, since 1979, has shown that the new system provides a workable and useful means for classifying not only perinatal deaths, but also late abortions, late neonatal deaths and perinatally related infant deaths. The rate of total perinatally related wastage, defined in this way, was almost twice that for perinatal mortality (22.8 compared with 11.9 per 1000 births). The former is advocated as a more realistic index for the audit of perinatal care. The revised and extended system is put forward as a contribution to the current debate on classifying and reporting such wastage, in the hope that it may be tested as a model for regional as well as hospital surveys.     

Perinatally related wastage–a proposed classification of primary obstetric factors

Summary. Adapting Sir Dugald Bairďs concept of primary obstetric causes of perinatal mortality, a revised clinico-pathological classification has been evolved to take account of new knowledge and developments, and to direct attention to potentially avoidable deaths and to where intensified efforts and investigation are needed. Categories highlighting the importance of intrauterine growth retardation, unexplained intrauterine death and spontaneous premature labour have been introduced, intrapartum hypoxia is separated from birth trauma, and infection again has its own category. Regular perinatal audit at one obstetric hospital, since 1979, has shown that the new system provides a workable and useful means for classifying not only perinatal deaths, but also late abortions, late neonatal deaths and perinatally related infant deaths. The rate of total perinatally related wastage, defined in this way, was almost twice that for perinatal mortality (22-8 compared with 11·9 per 1000 births). The former is advocated as a more realistic index for the audit of perinatal care. The revised and extended system is put forward as a contribution to the current debate on classifying and reporting such wastage, in the hope that it may be tested as a model for regional as well as hospital surveys.     

Perinatally related wastage—a proposed classification of primary obstetric factors

Summary. Adapting Sir Dugald Bairďs concept of primary obstetric causes of perinatal mortality, a revised clinico-pathological classification has been evolved to take account of new knowledge and developments, and to direct attention to potentially avoidable deaths and to where intensified efforts and investigation are needed. Categories highlighting the importance of intrauterine growth retardation, unexplained intrauterine death and spontaneous premature labour have been introduced, intrapartum hypoxia is separated from birth trauma, and infection again has its own category. Regular perinatal audit at one obstetric hospital, since 1979, has shown that the new system provides a workable and useful means for classifying not only perinatal deaths, but also late abortions, late neonatal deaths and perinatally related infant deaths. The rate of total perinatally related wastage, defined in this way, was almost twice that for perinatal mortality (22–8 compared with 11.9 per 1000 births). The former is advocated as a more realistic index for the audit of perinatal care. The revised and extended system is put forward as a contribution to the current debate on classifying and reporting such wastage, in the hope that it may be tested as a model for regional as well as hospital surveys.     

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.     

Regional population-based study on pregnancy outcomes in women with diabetes mellitus in Japan

AIM: We compared pregnancy outcomes in diabetic women with the background population in Miyazaki, Japan. METHODS: In 1998, we started the regional, population-based, peer-review conference to investigate the possible causes of perinatal deaths. For this purpose, at least one obstetrician and one neonatologist congregated from each institution (one tertiary and five secondary perinatal centers). A retrospective, population-based study was conducted in a total of 53 862 deliveries during 1999-2003. Among them, there were 248 perinatal deaths including six deaths in association with diabetes mellitus (DM). The number of diabetic pregnancies was estimated to be 381 during the study period. Perinatal mortality was compared between the diabetic women and background population by chi2-test. RESULTS: The perinatal mortality rate in diabetic women was 15.7 per 1000 deliveries, which was compared with 4.6 per 1000 in the background population (P = 0.003; odds ratio: 3.5; 95% confidence interval: 1.5-7.9). Four of the six perinatal deaths in diabetes were sudden intrauterine demises after 37 weeks' gestation, and the others were neonatal deaths of congenital heart anomaly or extreme prematurity. Most deaths were attributable to either undiagnosed or insufficient perinatal management. CONCLUSIONS: In an unselected population in Japan, diabetic women have 3.5 times the reported risk of perinatal mortality of the general population. Further improvements in the diagnosis and management of DM during pregnancy are required.     

Umbilical artery flow velocity waveforms and twin pregnancy outcome

Two hundred seventy-two twin pregnancies were studied by analysis of the fetal umbilical artery waveforms recorded using continuous-wave Doppler ultrasound. After the first 100 cases, a management strategy was adopted whereby all twin gestations would be studied between 28-32 weeks' gestation and the results made available to the referring obstetrician, thereby influencing clinical management. Perinatal mortality and morbidity, in pregnancies with both fetuses alive at 28 weeks' gestation, were compared between the patients studied in the first group of 100 and those studied after the Doppler examination was introduced as a clinical service. There was a decrease in perinatal mortality, both uncorrected (57.9 per 1000 to 17.9 per 1000; P less than .05) and corrected (42.1 per 1000 to 8.9 per 1000). Fetal deaths were reduced from six to one (P less than .05). This decrease in perinatal mortality was achieved without any appreciable change in the gestational age at delivery or mode of delivery between the two groups. There was a reduction in the number of infants requiring neonatal intensive care (from 38% to 24%; P less than .01).     

Systematic multidisciplinary approach to reporting perinatal mortality: Lessons from a five-year regional review

Background:  Because of differences in reporting criteria throughout the world, comparing perinatal mortality rates and identifying areas of concern can be complicated and imprecise.
Aims:  To detail the systematic approach to reporting perinatal deaths and to identify any significant differences in outcomes in the Australian Capital Territory (ACT).
Methods:  Review of perinatal deaths from 2001 to 2005 in the ACT using the Australian and New Zealand Antecedent Classification of Perinatal Mortality (ANZACPM) and the Australian and New Zealand Neonatal Death Classification (ANZNDC) systems.
Results:  ACT residents' perinatal mortality rate was 10.6 per 1000 total births, fetal death rate 7.5 per 1000 total births and neonatal death rate 3.2 per 1000 live births. The three leading antecedent causes of perinatal death were congenital anomalies, spontaneous preterm birth and unexplained antepartum death. The three leading causes of neonatal death were extreme prematurity, cardiorespiratory disorders and congenital anomalies. Multiple births attributed to 20% (65 of 321) of perinatal deaths. Perinatal autopsy was performed in 50% of cases, but in only 64% of unexplained antepartum deaths.
Conclusions:  Causes of perinatal death for the ACT and surrounding New South Wales region are similar to other states using this classification system. The following are considered important lessons to promote accurate perinatal mortality reporting: (i) a universal reporting system for Australia utilising a multidisciplinary team; (ii) a high perinatal autopsy rate, especially in the critical area of antepartum death with no identifiable cause; and (iii) standardised definitions for avoidability. Attention to these areas may prompt further research and changes in practice to further reduce perinatal mortality.     

Perinatal Mortality in a Tertiary Obstetric Institution

At the Royal Women's Hospital, Melbourne in the 3 years 1987-1989 analysis of the records of 13,347 public patients revealed an overall perinatal wastage of 20.8 per 1,000 births. This seemingly high figure resulted from the fact that 45% of losses occurred in nonbooked and emergency admissions. Many patients were referred with major complications of pregnancy, especially gross prematurity, lethal congenital malformations and intrauterine deaths. During the 3-year period 74% of perinatal losses occurred before 33 weeks' gestation and only 10% were after 37 weeks. By comparison at a Victorian State level, 47% of perinatal deaths occurred before 33 weeks and more than 35% after 37 weeks' gestation. The major causes of perinatal wastage in both groups were similar. At the Royal Women's Hospital in the 3-year period lethal congenital abnormalities accounted for 19.1% of fetal wastage, premature labour, premature rupture of the membranes and cervical incompetence 16.2%, multiple pregnancy 14.7%, antepartum haemorrhage 14.0% and hypertensive disorders 9.7%. During the 3-year period 7.7% of hospital stillbirths were intrapartum compared to 27% for the State of Victoria. The stillbirth rate in Victoria has declined over the past decade, but to a lesser extent than the neonatal death rate. Over the 3-year period 1987-1989 the ratio of stillbirths to neonatal deaths was 3 to 2, and in 1989 there were nearly twice as many stillbirths as neonatal deaths (424 versus 240). Furthermore, 55% of stillborn infants in Victoria had birth-weights of more than 1,500 g compared to the Royal Women's Hospital figure of 36%.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Perinatal mortality in twin pregnancies: a 3-year analysis in Seine Saint-Denis (France).

OBJECTIVES: Our purpose was to evaluate perinatal mortality in twins and to investigate factors associated with this mortality. STUDY DESIGN: A prospective study on the perinatal mortality was performed in the department of Seine-Saint-Denis. Out of all the perinatal deaths, we have retrospectively isolated those arising from twin pregnancies. RESULTS: There were 54 twin pregnancies complicated with perinatal death. The perinatal mortality rate in twin pregnancy was 78.0 per 1000 twin babies delivered. Out of 86 twin deaths, 38 (44.2%) were born before 28 weeks gestation and out of 82 twin perinatal deaths, 37 (45.1%) weighed less than 1000 g. Chorionicity was recorded in 44 twin pairs: 21 (47.7%) were dichorionic and 23 (52.3%) monochorionic. Finally, out of 48 twin sets there were four (8.3%) monoamniotic pregnancies. CONCLUSIONS: The present data show that extreme prematurity represents nearly half of perinatal mortality in twins. This study indicates also a significant proportion of monochorionic placentation among twin pregnancies with poor outcome.     

Maternal mortality in an urban hospital. A fifteen-year survey.

A 15-year survey of maternal mortality in a large urban hospital revealed an overall rate of 2.95 deaths per 10,000 pregnancies (3.44 per 10,000 live births), representing 31 maternal deaths among approximately 105,000 deliveries and spontaneous and therapeutic abortions. This rate showed marked improvement during the 15-year period, ie, 6.56 per 10,000 pregnancies for the first 5 years as compared to only 1.37 per 10,000 pregnancies for the last 10 years. In contrast to the classic triad of causes of maternal death--toxemia, hemorrhage, and spesis--the principal cause of death in this series was amniotic fluid embolism. Other aspects of the causes of death and of the findings are discussed. Among the 32 fetuses, total fetal wastage was 63%, with a neonatal mortality of 8% and a fetal mortality of 46%.     

Contribution of late fetal deaths to US perinatal mortality rates, 1995-1998

We analyzed US fetal death and linked infant birth-death certificate data for 1995-1998 to evaluate perinatal deaths (late fetal deaths [> or = 28 weeks' gestation] and early neonatal deaths [< or = 7 days of life]) by race, Hispanic ethnicity, state of residence, and selected demographic characteristics. We also compared components of perinatal mortality, late fetal deaths, and early neonatal deaths, by birthweight, gestational age, and selected maternal medical conditions during pregnancy. From 1995 through 1998, there were 221,767 fetal deaths at > or = 20 weeks' gestation and infant deaths at less than 1 year. Of these, 113,421 (51%) were perinatal deaths; late fetal deaths accounted for 47% of perinatal deaths. The total perinatal mortality rate declined 5.3%, from 7.5 to 7.1 per 1,000 live births plus late fetal deaths. Blacks experienced higher perinatal mortality rates than whites (rate ratio = 2.1). Among perinatal deaths > or = 28 weeks' gestation, the ratio of fetal to neonatal deaths was 3.4 among blacks and 2.4 among whites. State-specific rates ranged from 5.2 to 13.1 per 1,000 live births plus late fetal deaths. Although late fetal deaths are not included in routine statistics of pregnancy outcomes, these deaths represent a large proportion of adverse pregnancy outcomes. Surveillance of perinatal mortality provides a more complete picture of the health of women, fetuses, and newborns. Improving the quality of surveillance data regarding fetal deaths is essential for more effective use of these data. This information can be used to prevent excess perinatal deaths and reduce disparities in pregnancy outcomes among high-risk subgroups identified by individual and population characteristics.     

Implementing a facility-based maternal and perinatal health care surveillance system in Afghanistan

Afghanistan has one of the highest maternal and perinatal mortality rates in the world. Lack of a health information system presented obstacles to efforts to improve the quality of care and reduce mortality. To rapidly overcome this deficit in a large women's hospital, staff implemented a facility-based maternal and perinatal surveillance system known as "BABIES," which is specially designed for intervention and evaluation in low-resource settings. During a 12-month period, 15,509 deliveries resulted in 28 maternal deaths and a perinatal mortality rate of 56 per 1000 births. When stratified by birth weight and perinatal period of death, fetuses weighing at least 2500 g who died during the antepartum period contributed the most cases of perinatal death. This finding suggests that the greatest reduction in perinatal mortality would be realized by increasing access to high-quality antepartum care. Among fetuses weighing at least 2500 g, 93 deaths occurred during the intrapartum period. These deaths will continue to be monitored to ensure that the chosen interventions are improving intrapartum care for mothers and newborns. Because of its simplicity, flexibility, and ability to identify interventions, BABIES is a valuable tool that enables clinicians and program managers to prioritize resources.     

Cesarean delivery surveillance system at a maternity hospital in Kabul, Afghanistan

OBJECTIVE: To use an active facility-based maternal and newborn surveillance system to describe cesarean delivery practices and outcomes in a resource-poor setting. METHODS: Using data from operating room logbooks, 392 cesarean deliveries were evaluated between April 1 and June 30 2006 at a large public maternity hospital in Kabul, Afghanistan. RESULTS: The perinatal mortality rate was 89 per 1000 births: 57% antepartum and 37% intrapartum stillbirths. Fetuses with normal birth weight comprised 85% of intrapartum stillbirths. Obstructed labor, uterine rupture, and malpresentation accounted for more than 50% of perinatal deaths. The cesarean delivery rate was 10.2% and there were 2 maternal deaths. CONCLUSION: The high percentage of intrapartum stillbirths among normal birth weight fetuses suggests a need for improved labor monitoring and surgical obstetric practices. The use of a facility-based perinatal surveillance system is critical in guiding such quality assurance initiatives.     

Wessex Perinatal Mortality Survey 1982

Summary. A survey of 335 perinatal deaths in the Wessex region revealed a perinatal mortality rate of 10·1 per 1000 total births. Lethal malformations accounted for 82 (24%) deaths. Of the 253 normally formed infants, 124 (49%) died during pregnancy and 33 (13%) in labour. More than 60% of the stillbirths weighed >1500 g. Of the 96 postpartum deaths, half occurred within 24 h of delivery, mostly following complications of labour and circumstances suggesting hypoxia. The Aberdeen classification showed half of the mothers had pregnancy complications: other predisposing factors were identified in 10% of perinatal deaths. There were 185 neonatal deaths of which 150 occurred within 7 days and 35 within the next 3 weeks. Sixteen (46%) of the late neonatal deaths were due to a congenital abnormality; pregnancy or labour complications were present in six (32%) of the remaining 19 normally formed infants. Review of existing methods of antenatal supervision in particular, followed by the use of better monitoring systems for earlier detection of fetal distress and prompt action when indicated, together with improvement in neonatal care in the first 24 h after birth should further reduce the perinatal mortality.