Project Pró-Natal: Population-based Study of Perinatal and Infant Mortality in Natal, Northeast Brazil

The Pró-Natal project is a collaborative initiative that aims to improve maternal and infant health in a deprived community in Natal, Northeast Brazil. To assess the perinatal and infant mortality in this population of 40,000, we have collected over a 2-year period a consecutive series of 39 autopsy examinations on deaths under 1 year of age. During this period there were 2212 live births in the study population. The 14 perinatal deaths are described using the Wrigglesworth classification, and the 25 infant deaths, using a clinicopathological system. The contribution of normally formed stillbirths was small (14%), which probably reflects the underreporting of stillbirths in this community. The most common cause of death in the live births was complications of prematurity (43%). Specific causes (22%) of perinatal deaths were predominantly infections, including one case of congenital syphilis. Perinatal asphyxia was diagnosed in 14%, and there was one case (7%) of a chromosome abnormality. Infant deaths were predominantly due to respiratory (45%) and gastrointestinal infections (28%), with chronic malnutrition as an underlying cause in 80% of cases. Prenatal care could theoretically have prevented three of the perinatal deaths, and a further six deaths could have been avoided by improved management of labor and the immediate neonatal period. Prevention of malnutrition and improved treatment of acute infections would contribute to a reduction in infant mortality in this population. The Pró-Natal project will use these data to design preventative interventions to reduce perinatal and infant mortality in this community. Received September 1, 1998; accepted February 16, 1999.     

Perinatal and infant mortality in urban slums under I.C.D.S. scheme

Perinatal and infant mortality during the year 1985 was analyzed through a prospective study conducted in 12 Anganwadis (total population of 13,054) located in slum areas of India's Jabalpur city. Overall, the infant mortality rate was 128.7/1000 live births and the perinatal mortality rate was 88.5/1000 live births. 58.5% of deaths occurred in the neonatal period. Causes of neonatal deaths included prematurity, respiratory distress syndrome, birth asphyxia, septicemia, and neonatal tetanus. Postneonatal deaths were largely attributable to dehydration from diarrhea, bronchopneumonia, malnutrition, and infectious diseases. All mortality rates were significantly higher in Muslims than among Hindus. Muslims accounted for 28% of the study population, but contributed 63% of stillbirths and 55% of total infant deaths. This phenomenon appears attributable to the large family size among Muslims coupled with inadequate maternal-child health care. The national neonatal and postneonatal mortality rates are 88/1000 and 52/1000, respectively. The fact that the neonatal mortality rate in the study area was slightly lower than the national average may reflect the impact of ICDS services.     

Trends in perinatal and neonatal mortality and morbidity in India

Although the infant mortality rate (IMR) has reduced by 50% during the past century, it compares poorly with the advanced countries and some developing countries. The observed fall in IMR has been mostly in post-neonatal mortality, with the result that neonatal deaths now account for over 60% of all infant deaths. The overall perinatal mortality rate (PMR) in India is still over 50 per 1000 and has shown virtually no decline during the past decade, However, PMR differs widely in different states, urban/rural areas, different hospitals and so on. PMR is seen to correlate better with social development than economic development of the representative community. The causes of perinatal deaths suggest poor health of mother and poor health facilities and are hence potentially preventable. Various studies have shown that PMR can be significantly reduced within a short span of time. The registration of vital statistics continue to be highly unsatisfactory especially in rural areas.     

Infant mortality in a rural community development blockin haryana

This study was carried out to determine the infant mortality in a population of 95,000 in rural Haryana during 1980. The infant mortality rate was 774/1000 live births with 50% of the deaths occurring during the neonatal period. The main causes of death were prematurity (22.9%), acute lower respiratory tract disease (17.7%), febrile illness (14.6%) and congenital malformations (11.4%). Mortality due to acute diarrhoeal disease (5.2%) and neonatal tetanus (8.3% of neonatal mortalily) was much lower than reported from other rural areas in India. The lowered mortality in these two conditions was most likely due to the use of specific intervention programmes. Deaths occurred at home in 88% cases. Health care for the terminal illness was sought mainly from the health facility in the vicinity of the home (subcenter or primary health center). Registered medical practitioners (RMP) (90 cases) and village based health workers (84 cases) were contacted most often for the relief of symptoms. From these observations it is apparent that intervention measures for major preventable causes of infant mortality may go a long way in bringing down the mortality rates to acceptable levels. To achieve this, it is imperative to train the RMP and the village health volunteers whose help is most frequently sought.     

Social deprivation and the causes of stillbirth and infant mortality.

AIMS: To investigate the relation between social deprivation and causes of stillbirth and infant mortality. METHODS: Stillbirths and infant deaths in 6347 enumeration districts in Wales were linked with the Townsend score of social deprivation. In 1993-98 there were 211 072 live births, 1147 stillbirths, and 1223 infant deaths. Poisson regression analysis was used to estimate the magnitude of effect for associations between the Townsend score and categories of death by age and the causes of death. The relative risk of death between most and least deprived enumeration districts was derived. RESULTS: Relative risk of combined stillbirth and infant death was 1.53 (95% CI 1.35 to 1.74) in the most deprived compared with the least deprived enumeration districts. The early neonatal mortality rate was not significantly associated with deprivation. Sudden infant death syndrome showed a 307% (95% CI 197% to 456%) increase in mortality across the range of deprivation. Deaths caused by specific conditions and infection were also associated with deprivation, but there was no evidence of a significant association with deaths caused by placental abruption, intrapartum asphyxia, and prematurity. CONCLUSIONS: Collaborative public health action at national and local level to target resources in deprived communities and reduce these inequalities in child health is required. Early neonatal mortality rates and deaths from intrapartum asphyxia and prematurity are not significantly associated with deprivation and may be more appropriate quality of clinical care indicators than stillbirth, perinatal, and neonatal mortality rates.     

Infant mortality in southern Brazil: a population based study of causes of death.

The causes of 215 infant deaths occurring in a population based cohort of 5914 infants from southern Brazil were determined. Perinatal problems were responsible for 43% of these deaths and infectious diseases for 32%. In the group who died of infectious diseases, respiratory infections and diarrhoea were equally important, each accounting for 12% of all deaths. A total of 87% of the deaths occurred in the first six months of life, and this proportion remained high (77%) even after perinatal causes had been excluded. On the other hand, 53% of the infants who died were of low birth weight, as opposed to 7.9% of the survivors. This suggests that low birthweight infants need to be carefully followed by health workers at primary level, especially during the first six months. It was estimated that if the incidence of low birth weight was reduced from the present 8.8% to 5% the likely reduction in infant mortality would be 20%. This reduction would be 33% for deaths due to perinatal causes, 14% for respiratory infections, and only 5% for diarrhoea. Efforts for the prevention of infant deaths in southern Brazil are more likely to be effective if they concentrate on improving perinatal health care and environmental conditions.     

Social deprivation and the causes of stillbirth and infant mortality

AIMS—To investigate the relation between social deprivation and causes of stillbirth and infant mortality.METHODS—Stillbirths and infant deaths in 6347 enumeration districts in Wales were linked with the Townsend score of social deprivation. In 1993-98 there were 211 072 live births, 1147 stillbirths, and 1223 infant deaths. Poisson regression analysis was used to estimate the magnitude of effect for associations between the Townsend score and categories of death by age and the causes of death. The relative risk of death between most and least deprived enumeration districts was derived.RESULTS—Relative risk of combined stillbirth and infant death was 1.53 (95% CI 1.35 to 1.74) in the most deprived compared with the least deprived enumeration districts. The early neonatal mortality rate was not significantly associated with deprivation. Sudden infant death syndrome showed a 307% (95% CI 197% to 456%) increase in mortality across the range of deprivation. Deaths caused by specific conditions and infection were also associated with deprivation, but there was no evidence of a significant association with deaths caused by placental abruption, intrapartum asphyxia, and prematurity.CONCLUSIONS—Collaborative public health action at national and local level to target resources in deprived communities and reduce these inequalities in child health is required. Early neonatal mortality rates and deaths from intrapartum asphyxia and prematurity are not significantly associated with deprivation and may be more appropriate quality of clinical care indicators than stillbirth, perinatal, and neonatal mortality rates.     

Infant and early childhood mortality in urban slums under ICDS scheme--a prospective study

The infant and early childhood mortality, its causes and associated factors were studied prospectively, in twelve Anganwadi centres, situated in urban slums of Patna from 1st January, 1987 to 31st December, 1987. A strict recording of births and deaths was done by Anganwadi workers, with monthly verifications by authors. The causes of death were established on the basis of clinical and corroborative enquiry from the parents. The birth rate was found to be 29.25, death rate 13.1, infant mortality rate 64.65/1000. Neonatal and post neonatal mortality rates were 49.42/1000 and 15.21/1000, respectively. Mortality in children between 1-3 years (11.3/1000) was higher in comparison to that of 3-6 years (9.1/1000). Low birth weight (25.52%) and perinatal infection (23.52%) were the major causes of infant mortality followed by respiratory infection (11.76) and diarrhea (8.82%). Diarrhea (37.5%), respiratory infection (15.62%) and accidents and burns (12.5%) were major killers in children between 1-6 years. Mortality in males was higher than females in infancy. Risk factors associated with infant mortality included extremes of maternal age (less than 20 and greater than 30 years), multiparity and illiterate mothers.     

Infant mortality in Pondicherry--an analysis of a cohort of 8185 births.

Infant mortality rate is one of the 12 global indicators for monitoring Health for All. Reliable data on infant mortality are not available for the majority of developing countries including India. To plan strategies for bringing down the rate and, later, to evaluate them, 'Cause Specific Rates' would be necessary. Pondicherry has achieved low rates of infant mortality. A study was conducted in the Anganwadis of Pondicherry to determine the causes of infant deaths. The 8185 children born between 1-4-1987 and 31-3-1988 in Pondicherry formed the study group. The Anganwadi workers collected information on the cause of death for the 222 children dying within the first year. The infant mortality rate was 27.1 per 1000 live births. Acute respiratory infections and diarrheal diseases accounted for 45% of the deaths.     

Mortality from birth to adult life: a longitudinal study of twins

We have examined mortality from birth through adult life in a cohort of 2562 twins born in Birmingham, UK, between 1950 and 1954. Their birthweights and obstetric details had been recorded as part of a longitudinal study of births in Birmingham. There were a total of 151 perinatal deaths (perinatal mortality rate = 116 per 1000 births) and 227 infant deaths (infant mortality rate = 94 per 1000 live births). 70 deaths occurred after the age of one year. In comparison with national mortality rates in the UK, overall mortality in the twins was high (standard mortality rate, SMR = 259, 95% CI 221-300). Mortality was highest in the first year of life and, although it then declined progressively, it remained significantly higher that that of the general population until age 5 years. The excess mortality was largely due to conditions originating in the perinatal period but there were excess rates of congenital abnormalities, diseases of the respiratory system, digestive system and nervous and sensory organs. A Cox proportional Hazards analysis showed that the risk of death was related to low birthweight, prematurity and male sex. Death of the co-twin was highly predictive of mortality throughout the period of follow up. These studies not only underline the excess mortality associated with twin birth but show for the first time that this excess mortality extends into childhood.     

Strategies to reduce perinatal and neonatal mortality

The perinatal mortality rate in India averages 66.3/1000 live births. 60% of all infant deaths occur during the 1st month, making the neonatal mortality rate 76/1000 in rural areas and 39/1000 in urban areas. These rates have remained static since 1974. Over 90% of all deliveries occur at home and are conducted by untrained birth attendants. The major causes of perinatal deaths are immaturity/low birth weight, birth asphyxia/trauma, neonatal infections, and congenital malformations. Neonatal tetanus alone is responsible for 230,000-280,000 deaths a year. Hypoxia, low birth weight, and tetanus are preventable, if primary perinatal care is provided and high-risk pregnancies are recognized and referred to facilities where fetal monitoring and neonatal care are available. It is proposed to train all of the country's 5 million traditional birth attendants by 1990 to deliver primary perinatal care. By 1990 also there will be 1 village health guide for every 1000 people. All traditional birth attendants must know how to give mouth-to-mouth resuscitation, and the infrastructure for an adequate referral system must be established. In order to reduce the incidence of low birth weight, the Integrated Child Development Service Scheme proposes that all pregnant women receive a dietary supplement of 500 calories and 25 gm protein, and that pregnant women be given a 2-hour midday rest period. The control of malaria and intestinal infections with chloroquine and antibiotics would do much to reduce low birth weight. Simple technologies for measuring birth weight indicators, such as chest circumference or mid-arm circumference, require only a tape measure. Finally, technics of mass communication must be utilized to spread knowledge of perinatal and neonatal care.     

Changes in the neonatal and infant mortality rate and the causes of death in Korea

Neonatal mortality rate (NMR) or infant mortality rate (IMR) are the rate of deaths per 1,000 live births at which babies of either less than four weeks or of one year of age die, respectively. The NMR and IMR are commonly accepted as a measure of the general health and wellbeing of a population. Korea's NMR and IMR fell significantly between 1993 and 2009 from 6.6 and 9.9 to 1.7 and 3.2, respectively. Common causes of infantile death in 2008 had decreased compared with those in 1996 such as other disorders originating in the perinatal period, congenital malformation of the heart, bacterial sepsis of newborns, disorders related to length of gestation and fetal growth, intra-uterine hypoxia, birth asphyxia. However, some other causes are on the increase, such as respiratory distress of newborn, other respiratory conditions originating in the perinatal period, other congenital malformation, diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism. In this study, we provide basic data about changes of NMR and IMR and the causes of neonatal and infantile death from 1983 to 2009 in Korea.     

A study of perinatal mortality rate from rural based Medical College Hospital

The present study conducted in a rural medical college aimed at analysing the perinatal mortality and its determinants in a rural set up. Fiftyeight still births and sixty two early neonatal deaths among 1107 consecutive deliveries gave a perinatal mortality rate of 108.4 per 1000 deliveries. Fifty percent of the total deliveries were unbooked. The perinatal mortality was higher in unbooked cases (16.3%), twins (33.2%) and preterms (33.9%) as compared to that in booked cases (5.3%), singletons (9.6%) and term deliveries (6.7%). Sixty nine percent of the still births were due to causes like obstructed labour, toxemia of pregnancy, antepartum hemorrhage, hand prolapse, and cord prolapse where timely intervention would have reduced the perinatal mortality significantly. Early neonatal deaths were mainly associated with prematurity and were largely due to birth anoxia, intraventricular hemorrhage, aspiration and infections.     

Trends in perinatal, neonatal and post-neonatal mortality in Austria and Tyrol, with special reference to 1979-1988]

Analysis of neonatal, perinatal and infant mortality rates is a useful basis to compare the quality of neonatal care in a country. During the last decades these parameters have been falling steadily in Austria as well as in other industrialized countries. Regarding the various provinces of Austria substantial regional differences occur. Apparently the decline in mortality rates is not only contributable to medical progress but as strongly influenced by social and economic changes. In the mid-seventies absolute and relative neonatal mortality rates in Austria definitely decreased, most probably attributable to the installation of neonatal intensive care units. During 1968-1978 the decrease in neonatal mortality was mainly due to reduced first-day-mortality, whereas during the following decade it was mainly due to reduced mortality of the 2nd until 7th day of life. Interestingly, the rate of preterm infants in Austria remained virtually constant during 1968-1988 despite improved pre- and perinatal care. Paralleling the development in full-term neonates the peri-/neo- and postneonatal mortality rates of preterm infants decreased. Predictably - as in other countries - the highest improvement was found in the low birth weight groups Nevertheless, premature births have accounted for the majority of neonatal and perinatal deaths.     

A study of perinatal mortality rate from rural based Medical College Hospital

This study was conducted at a rural medical college and aimed at analysis of the perinatal mortality and its determinants in a rural environment. 58 stillbirths and 62 early neonatal deaths among 1107 consecutive deliveries effected a perinatal mortality rate of 108.4/1000 deliveries. 50% of the total deliveries were unbooked. The perinatal mortality was higher in unbooked cases (16.3%), twins (33.2%), and preterm deliveries (33.9%) as compared to that in booked cases (5.3%), singletons (9.6%), and term deliveries (6.7%). 69% of the stillbirths were the result of obstructed labor, toxemia, antepartum hemorrhage, hand prolapse, and cord prolapse where timely intervention would have reduced the perinatal mortality significantly. Early neonatal deaths were mainly associated with prematurity and were due largely to birth anoxia, intraventricular hemorrhage, aspiration, and infections.     

Infant mortality in rural India: a strategy for reduction

A risk-approach-strategy project sponsored by WHO was undertaken in 22 villages of Surur, Pune, by BJ Medical College. All births in the study population of 47,000 were followed, comparing the 3 cohorts born between January 1981 to December 1983. Female village health guides were trained in screening for 11 maternal risk factors, infant risk factors, infant monitoring, and basic health support such as maternal nutrition, rest, breastfeeding and home cleaning, heating, humidifying and infant isolation. There were 123, 97 and 87 infant deaths in the 1981, 1982, and 1983 cohorts, giving infant mortality rats of 91.2, 72.3 and 67.3 respectively. The proportion of neonatal deaths remained at 61 to 62.1% over the period. The most common risk factors seen were illness, low birth weight and growth retardation, often associated with illness. Incidence of low birth weight and prolonged labor both decreased significantly over the duration of the program. Mortality was high among infants with feeding problems and prematurity. 40% of deaths were due to infections, 28% to low birth weight and prematurity, and 9% to birth asphyxia. The lower infant mortality rate achieved here is comparable to urban levels reported in India. These results show that primary health workers are capable of referring and managing risks, and risk management could be applied on a larger scale.     

Perinatal care in Portugal: effects of 15 years of a regionalized system

AIM: To share information on the organization of perinatal care in Portugal. METHODS: Data were derived from the Programme of the National Committee for Mother and Child Health 1989, National Institute for Statistics, and Eurostat. RESULTS: In 1989, perinatal care in Portugal was reformed: the closure was proposed of maternity units with less than 1500 deliveries per year; hospitals were classified as level I (no deliveries), II (low-risk deliveries, intermediate care units) or III (high-risk deliveries, intensive care units), and functional coordinating units responsible for liaison between local health centres and hospitals were established. A nationwide system of neonatal transport began in 1987, and in 1990 postgraduate courses on neonatology were initiated. With this reform, in-hospital deliveries increased from 74% before the reform to 99% after. Maternal death rate decreased from 9.2/100,000 deliveries in 1989 to 5.3 in 2003 and, in the same period, the perinatal mortality rate decreased from 16.4 to 6.6/1000 (live births + stillborn with > or = 22 wk gestational age), the neonatal mortality rate decreased from 8.1 to 2.7/1000 live births, and the infant mortality rate from 12.2/1000 live births to 4/1000. CONCLUSION: Regionalization of perinatal care and neonatal transport are key factors for a successful perinatal health system.     

Infant mortality increase despite high access to tertiary care: an evolving relationship among infant mortality, health care, and socioeconomic change

In this study, the determinants of an apparent increase in the infant mortality rate of an urban population with high access to tertiary neonatal care are reviewed. For a 4-year period (1980 to 1983), all infant deaths (n = 422) of the 32,329 births to residents of the City of Boston were analyzed through linked vital statistics data and a review of medical records. A significant increase in the infant mortality rate occurred in 1982 due to increases in three components of the infant mortality rate: the birth rate of very low birth weight infants (less than 1,500 g), the neonatal mortality rate of normal birth weight infants (greater than or equal to 2,500 g), and the mortality rate of infants dying during the postneonatal period (28 to 365 days). These increases were associated with inadequate levels of prenatal care. Although transient, the impact of the observed alterations in these infant mortality rate components was enhanced by a more long-standing phenomenon: the stabilization of mortality rates for low birth weight infants. This stabilization allowed the increases in other component rates to be expressed more fully than in previous years. In this report a mechanism is shown whereby fully regionalized neonatal care ultimately may confer to the infant mortality rate a heightened sensitivity to socioeconomic conditions and levels of adequate prenatal care.     

Neonatal morbidity and mortality in a Tanzanian tertiary care referral hospital

In developing countries, neonatal mortality accounts for 50-70% of infant mortality. The purpose of this study was to describe morbidity and mortality patterns, with a focus on neonatal infections, in a Tanzanian special care baby unit (SCBU). During a 3-month period, 246 consecutive admissions to the SCBU at Kilimanjaro Christian Medical Centre were audited. Prematurity, low birthweight and suspected infection accounted for 61% of all admissions. The overall mortality rate was 19%, but varied considerably according to gestational age, birthweight and diagnosis. Thirty-one neonates (two-thirds of all deaths) died during the 1st 24 hours of life. Of 27 infants admitted on grounds of perinatal asphyxia, 11 (41%) died, and, of 19 infants with a gestational age <31 weeks, 13 (68%) died. More than two-thirds of all infants were treated with antibiotics. Septicaemia confirmed by blood culture was found in 16 cases. The susceptibility pattern of bacterial isolates did not indicate high rates of resistance to commonly used antibacterial agents. A reduction in the number of preterm deliveries and improved perinatal care to avoid and treat perinatal asphyxia would be the two most important measures in reducing neonatal mortality in this setting.     

Intervention strategies for reduction of infant mortality

The Government of India has established the goal of a 50% reduction in the infant mortality rate by the year 2000 for the country as a whole as well as for each state and union territory. Experience has indicated that this is an achievable goal provided that the appropriate, cost-effective interventions are introduced. Choice of intervention strategies requires consideration of the contribution of various problems to overall infant mortality, the technical feasibility of various interventions within the context of primary health care, economic feasibility, and cultural acceptability. About 50% of deaths occur in the neonatal period, and the determinants of mortality in this stage differ from those in the postneonatal period. Pilot experiments have indicated that acute diarrheal disease can be reduced substantially by the use of oral rehydration solution. Neonatal tetanus is a completely preventable disease. Preventive interventions have a more limited role in the case of acute lower respiratory infections, although their diagnosis and treatment may be possible at the primary health care level. The problems of protein-energy malnutrition and low birthweight require improvements in maternal health and prenatal care, promotion of breastfeeding and child spacing, and growth monitoring. Longterm gains in this area require attention to behavioral and community development issues, including reduction of the sex and parity related differentials in mortality, enhancement of the status of women, improved female literacy and employment opportunities, improved intrafamilial food distribution patterns, maternity benefits, provision of potable water, intersectoral development to strengthen health care delivery, increased community participation, expanded health services, and enhancement of the pace of development. Pilot experiments and population-based studies carried out in 2 community development blocks in Haryana confirm the effectiveness of well thought-out interventions in reducing infant mortality.