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.     

Hemoglobin concentration in pregnancy and perinatal mortality: a London-based cohort study

OBJECTIVE: Failure of fetal growth during pregnancy, and preterm birth, are the major causes of stillbirth and early neonatal death. The objective of the study was to determine the association between maternal hemoglobin concentration during pregnancy and perinatal mortality. STUDY DESIGN: The design was prospective, using data on 222,614 first singleton pregnancies in the St Mary's Maternity Information System database in the Northwest Thames region of London. RESULTS: The association of perinatal mortality with maternal hemoglobin at first antenatal check was not statistically significant (P>.10), but a statistically significant (P<.001) U-shaped pattern was found with lowest recorded maternal hemoglobin concentration. Both early neonatal mortality and stillbirth rates were statistically significantly (P<.005) associated with lowest maternal hemoglobin concentration. The relationship of lowest hemoglobin with early neonatal mortality was largely mediated by the effect of preterm birth, and that between lowest hemoglobin and stillbirth by fetal growth restriction. The lowest perinatal mortality was associated with a lowest recorded maternal hemoglobin concentration of between 9-11 g/dL. CONCLUSION: There is an optimal range of lowest hemoglobin concentration in pregnancy, and on either side of this perinatal mortality is increased. The effect of lowest hemoglobin is largely mediated through associations with preterm birth and fetal growth restriction.     

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.     

A critical analysis on Italian perinatal mortality in a 50-year span

BACKGROUND: Perinatal mortality rate is used as an indicator of reproductive health worldwide. In western countries, national mortality registers are usually accurate and reliable. METHODS AND AIMS: We reviewed the data recorded in the past 50 years in Italy on perinatal and infant mortality. Each single class of mortality rate (according to WHO definitions) was assessed on temporal trends allowing a critical speculative analysis, mainly focusing on the last 20 years, in an attempt to evaluate the impact of prenatal diagnosis. RESULTS: Infant mortality rate (IMR) constantly decreased in the study period whereas early neonatal mortality rate progressively diminished in a 5-year comparison till the early 1990s. Perinatal mortality showed a linear negative trend until the 1980s, after which the decrease steadied at about 23% in the following 5-year period. Infant mortality attributable to congenital anomalies throughout a 20-year span (1980-2000) was steady at about 23% although a progressive reduction in general infant mortality was reported. CONCLUSIONS: A higher reduction in neonatal and perinatal mortality rate was found before the wide availability of the ultrasonographic prenatal diagnosis and the introduction of the law on voluntary abortion in Italy. Given these data, it seems that advances in neonatal care have improved the infant survival rates more than prenatal diagnosis, whereas obstetric care is linked to a reduction of the early perinatal mortality rate.     

Ischemic placental disease and risks of perinatal mortality and morbidity and neurodevelopmental outcomes

Preeclampsia, intrauterine growth restriction, and placental abruption are serious obstetrical complications that constitute the syndrome of ischemic placental disease and account for a disproportionate degree of perinatal morbidity and mortality. We review the risks of stillbirth and neonatal and infant mortality in relation to ischemic placental disease, focusing on population-based studies. We also review the risks of neonatal morbidity and neurodevelopmental outcomes in relation to ischemic placental disease. A synthesis of the findings of the relevant studies relating ischemic placental disease to adverse perinatal outcomes underscores two important observations. First, despite the low prevalence of each of the three obstetrical complications, all are associated with increased risks of adverse perinatal and infant outcomes, as well as neurodevelopmental deficits. Second, the burden of increased perinatal risks appears strongest during the preterm period. Efforts to reduce the risks of ischemic placental disease remain critically important and developing effective clinical interventions will be a target worthy for consideration.     

Clinical causes and classification of perinatal mortality in Lagos

Perinatal deaths in singleton births at the Lagos University Teaching Hospital during a 5-year period were reviewed. Causes of deaths were classified into eight groups using a modified form of the Aberdeen classification. Perinatal mortality was high (42.5/1000 total births). The stillbirth rate was 32.5/1000 total births. The major causes of perinatal mortality were trauma (30.5%), low birth weight (23.9%), hemorrhage (13.7%), toxemia of pregnancy (10.3%) and mature, cause unknown (10%). Congenital malformation (4.3%) was not a major cause of perinatal deaths in this study.     

HELLP综合征并发围生儿死亡危险因素分析

目的:探讨HELLP综合征并发围生儿死亡的危险因素。方法:回顾分析1991年1月至2010年12月天津市中心妇产科医院收治的76例HELLP综合征患者临床资料,按是否发生围生儿死亡分为死亡组和对照组,比较两组患者的一般临床资料和各项实验室指标。结果:围生儿死亡率为22.4%(17/76)。卡方检验结果显示:生产次数、早产情况、胎儿窘迫、收缩压、舒张压、血红蛋白、血小板计数、血清胆红素、24h尿蛋白定量为影响HELLP综合征并发围生儿死亡有统计学意义的因素(P<0.05);Logistic回归分析结果显示:舒张压、血红蛋白、血小板计数、血清胆红素、24h尿蛋白定量是影响HELLP综合征中围生儿死亡有统计学意义的因素。结论:血红蛋白和血小板计数降低及血清胆红素、舒张压和24h蛋白尿升高是影响HELLP综合征围生儿死亡的危险因素。     

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.     

Younger maternal age (at initiation of childbearing) and recurrent perinatal mortality

Objective

To assess whether young maternal age at initiation of childbearing is associated with recurrence of perinatal mortality (PM), as well as its components: stillbirth and neonatal death.

Study design

We conducted a population-based, retrospective cohort study on the Missouri maternally linked longitudinal data files comprising adolescent (10-19 years; n = 73,533) or mature (20-24 years; n = 78,618) mothers in their first pregnancy with follow-up in their second pregnancy to document the occurrence of PM or its components. The study covered the period 1989-2005. We used unconditional logistic regression modeling to generate odds ratios and to control for confounding.

Results

A history of perinatal mortality, stillbirth, or neonatal mortality increased the risk of a recurrence by 4-5 times. Among women with a history of PM or stillbirth in the first pregnancy, maternal age at initiation of pregnancy was not a risk factor for subsequent PM or its components. However, adolescent mothers with a history of neonatal mortality in the first pregnancy were about 5 times as likely to experience stillbirth in the second pregnancy, as compared to their mature counterparts.

Conclusions

Young maternal age at the initiation of childbearing is not associated with an overall increased risk of recurrent perinatal loss. However, prior history of neonatal mortality among teen mothers is strongly predictive of subsequent stillbirth.     

Risk factors for perinatal mortality in patients admitted to the hospital with the diagnosis of placental abruption

Objective: Placental abruption is a clinical term used when premature separation of the placenta from the uterine wall occurs prior to delivery of the fetus. Hypertension, substance abuse, smoking, intrauterine infection and recent trauma are risk factors for placental abruption. In this study, we sought for clinical factors that increase the risk for perinatal mortality in patients admitted to the hospital with the clinical diagnosis of placental abruption.

Materials and methods: We identified all placental abruption cases managed over the past 6 years at our Center. Those with singleton pregnancies and a diagnosis of abruption based on strict clinical criteria were selected. Eleven clinical variables that had potential for increasing the risk for perinatal mortality were selected, logistic regression analysis was used to identify variables associated with perinatal death.

Results: Sixty-one patients were included in the study with 16 ending in perinatal death (26.2%). Ethnicity, maternal age, gravidity, parity, use of tobacco, use of cocaine, hypertension, asthma, diabetes, hepatitis C, sickle cell disease and abnormalities of amniotic fluid volume were not the main factors for perinatal mortality. Gestational age at delivery, birthweight and history of recent trauma were significantly associated with perinatal mortality. The perinatal mortality rate was 42% in patients who delivered prior to 30 weeks of gestation compared to 15% in patients who delivered after 30 weeks of gestation (p?<?0.05). A three-fold increase in severe trauma was reported in the group of patients with perinatal mortality than in the group with perinatal survivors (25% versus 7%, respectively, p?<?0.05).

Conclusions: In patients admitted to hospital for placental abruption delivery prior to 30 weeks of gestation and a history of abdominal trauma are independent risk factors for perinatal death.     

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.     

Decreased perinatal mortality among women with diet-controlled gestational diabetes mellitus

Objective

To examine pregnancy outcomes associated with diet-controlled gestational diabetes mellitus (GDM A1).

Methods

A retrospective cohort study compared pregnancy characteristics of women with and without GDM A1 at a center where GDM A1 patients are routinely induced at 40 weeks.

Results

Higher rates of complications such as shoulder dystocia, congenital malformation, and macrosomia were observed in GDM A1 patients. A lower incidence of perinatal mortality was present in GDM A1 women compared with women without GDM A1. This association lost its significance when controlled for maternal age, ethnicity, induction, cesarean delivery, and birth weight in a multivariate model. Although the stillbirth rate before 40 weeks of gestation was identical among all participants, after 40 weeks it was significantly higher in women without GDM A1.

Conclusion

Induction of women with GDM A1 at 40 weeks may play a role in lowering perinatal mortality to below that of the general population.     

10年间剖宫产率及指征变化与围生儿死亡率的关系

目的：探讨剖宫产率及剖宫产指征变迁对围生儿死亡率的影响。方法：对10年间剖宫产病例资料进行回顾性分析。结果：1992－1996年剖宫产率为36．50％，显著低于1997－2001年的47．78％，两者比较，差异有极显著性（P＜0．01）。在剖宫产指征中，妊娠并发（合并）症始终处于第1位，社会因素上升为第2位，难产为第3位，胎儿窘迫为第4位。围生儿死亡率1992－1996年为17．88‰，1997-2001年为22．23‰，两者比较，差异无显著性（P＞0．05）。结论：剖宫产率升高在一定范围内降低了围生儿死亡率，但随着剖宫产率的进一步升高，围生儿死亡率并未随之下降。因此，应合理掌握剖宫产指征，降低剖宫产率。     

Fetal growth and perinatal mortality in twin pregnancy - effect of sick leave and hospitalization

Fetal growth, birth weight specific mortality rates and effect of sick leave or hospitalization on the fetal growth were investigated in a material of 476 twin pregnancies managed at University Central Hospital of Turku in year 1970–1981. Birth weights of twin babies at any gestational age were slightly but not significantly higher than in earlier materials. When compared to growth curve of singleton fetuses, the growth rate of both twins is equal to singletons up to 30th week of pregnancy, being thereafter slower than in singleton pregnancies.Although duration of sick leave and hospitalization increased considerably during the study period, no change in the duration of pregnancy nor in the weight of twin babies occurred. Instead perinatal mortality decreased from 101/per thousand to 36.2/ per thousand. Birth weight specific mortality rates did not differ from those in singleton fetuses.     

Re. Co. De.: A Better Classification for Determination of Still Births

Objective

To test the classification system Re. Co. De. to improve our understanding of the main causes associated with fetal deaths.

Method

The study included 348 women who were admitted with intrauterine deaths. After the stillborn babies were examined along with the placenta. The causes were classified according to Re. Co. De. system.

Results

The analysis of the new classification (Re. Co. De.) allowed attributable causes to about 90% of cases of stillbirth explained while 10% where unexplained. The commonest cause was found to be toxaemia of pregnancy, followed by IUGR, rupture uterus, obstructed labour, abruptio placentae etc.

Conclusion

The Re. Co. De. system gives us a better understanding of antecedents of stillbirth and the clinical practices, which need to be addressed to reduce perinatal mortality and have a better obstetric result in the next pregnancy.     

Lack of prenatal care: an independent risk factor for perinatal mortality among macrosomic newborns

Objective To examine the association between lack of prenatal care (LOPC) and perinatal complications among parturients carrying macrosomic fetuses. Study design The study population consisted of consecutive women with singleton fetuses weighing 4 kg and above, delivered between the years 1988 and 2003. A comparison was performed between parturients lacking prenatal care (fewer than three visits at any prenatal care facility) and those with three and more prenatal care visits. A multiple logistic regression model was constructed in order to investigate the association between LOPC and perinatal mortality. Results During the study period, 7,332 women delivered macrosomic newborns in our institute. Of those, 8.0% (n = 590) lacked prenatal care. Patients lacking prenatal care were more likely to be Bedouins, of higher parity and older than the comparison group. Higher rates of perinatal mortality were noted among patients lacking prenatal care (OR = 5.4, 95%CI 2.8–10.5; P < 0.001). Using a multivariable analysis and controlling for macrosomia-related complications, it was found that the association between LOPC and perinatal mortality persisted (OR = 4.1, 95% CI 2.1–8.1; P < 0.001). Conclusion Lack of prenatal care is an independent risk factor for perinatal mortality among macrosomic newborns.     

Monitoring perinatal mortality by birth weight specific mortality rates

The perinatal mortality at University Central Hospital of Turku, Finland decreased significantly from 15.7/1000 in years 1970-75 to 8.9/1000 in years 1976-78. The main decrease has occurred in weight groups of 1000 g and more. In years 1976-78 the perinatal mortality of non-malformed babies in the weight group 1500-1999 g was 93/1000, in the group 2000-2499 g 21/1000 and in the group of 2500 g and over 1.7/1000. The early neonatal mortality of non-malformed infants has decreased significantly only in the weight group of 1500-1999 g. The 1-week survival rate has been 48% in the weight group 500-999 g, but 77% in the weight group 1000-1499 g. The birth weight specific mortality rates are greatly required when the quality of obstetrical care is assessed. Birth weight specific neonatal mortality rates are essential when guidelines for elective termination of third trimester pregnancy are designed.     

Pilot community-mobilization program reduces maternal and perinatal mortality and prevents obstetric fistula in Niger

Objective

To assess the impact of a pilot community-mobilization program on maternal and perinatal mortality and obstetric fistula in Niger.

Methods

In the program, village volunteers identify and evacuate women with protracted labor, provide education, and collect data on pregnancies, births, and deaths. These data were used to calculate the reduction in maternal mortality, perinatal mortality, and obstetric fistula in the program area from July 2008 to June 2011.

Results

The birth-related maternal mortality fell by 73.0% between years 1 and 3 (P < 0.001), from 630 (95% confidence interval [CI] 448–861) to 170 (95% CI 85–305) deaths per 100 000 births. Early perinatal mortality fell by 61.5% (P < 0.001), from 35 (95% CI 31–40) to 13 (95% CI 10–16) deaths per 1000 births. No deaths due to obstructed labor were reported after the lead-in period (February to June 2008). Seven cases of community-acquired fistula were reported between February 2008 and July 2009; from August 2009 to June 2011 (23 months; 12 254 births), no cases were recorded.

Conclusion

Community mobilization helped to prevent obstetric fistula and birth-related deaths of women and infants in a large, remote, resource-poor area.