Neonatal mortality patterns in an urban hospital.

Neonatal mortality rate is perhaps the most reliable indicator of the perinatal outcome. An assessment of perinatal outcome can be made through knowledge of causes of death. This study was carried out to evaluate the neonatal deaths in our hospital. Live births (n = 7309) and deaths (n = 328) during a 6 months period were retrospectively analyzed. These were grouped into non-preventable and potentially preventable causes of death. The single most important factor contributing to the mortality was respiratory distress (29.3%) followed by sepsis (24.4%) and birth asphyxia (16.2%). The non-preventable causes of mortality (e.g., lethal congenital malformations, extremely low birth weight) accounted for 10.4% of the total mortality. The idealized neonatal mortality rate was 4.6/1000 live births, while the salvageable death rate was 40.2/1000 live births. The mortality increased significantly if the birth weight fell below 2 kg. The salvageable deaths could perhaps be prevented through better antenatal and intranatal care, ventilatory support and prevention of sepsis.     

Infant mortality in a region of Finland, 1968–1982

Infant mortality in a region of Finland with about 450000 people and 5400 annual births was examined during a 15-year period, 1968–1982. Total infant mortality declined from 15.8 per 1000 live births in 1968 to 5.0 in 1982. The lowering of neonatal mortality accounted for the decline, as postneonatal mortality remained at the same level throughout the study period. Despite a decrease of nearly 80%, perinatal disorders remained the leading category of primary causes of death. Mortality from congenital malformations decreased by 50%, mortality from sudden infant death syndrome increased from 0.2 to 0.9 per 1000 live births while mortality from accidents, infectious diseases and other diseases remained minor causes of death with no change in frequency. In the low birth weight category, postponement of deaths from early to late neonatal and postneonatal periods occurred, but total infant mortality in the low birth weight category declined by about 60%. During the last two 3-year periods, decrease in birth weight-specific infant mortality was found in the 500–999 g and >2500 g categories. The reasonably high standard of living, good educational level of mothers, well organized primary maternal and child health services and the rapid advances in obstetric and neonatal care equally available and regionalized, have contributed to the favourable progress in infant mortality in Finland.     

Early neonatal mortality in Caxias do Sul: a cohort study

OBJECTIVES: To establish the profile of neonates in Caxias do Sul city, and to study early neonatal mortality, its causes and related variables.METHODS: This cohort study enrolled 5,545 newborns, which were followed up to 7 days after birth. The probability of early neonatal mortality was calculated and multiple logistic regression was performed to relate all studied variables to the outcome of early neonatal death.RESULTS: The observed probability of early neonatal mortality was 7.44 per thousand live births. The incidence of premature births and low birth weight was 9.4% and 8.1%, respectively. Fifty five percent of the neonates were born through cesarean section, which were related to socioeconomic and educational level. Previous history of neonatal mortality, maternal age > 35 years, gestational age, Apgar score < 7, male sex and low birth weight were related to early neonatal death. The main cause of death was hyaline membrane disease, followed by congenital cardiopaties, extreme preterm and abruptio placentae.CONCLUSION: Even though the observed probability of early neonatal mortality was low, some deaths may have been avoided if better prenatal and delivery care, as well as newborn assistance had been offered.     

Early neonatal mortality in an intramural birth cohort at a tertiary care hospital

Early neonatal mortality (ENM) occurring among 12,283 consecutive live birthsover a period of 3 years were analysed. The early neonatal mortality rate (ENMR) was 26.6/1000 live births. Birth weight less than 2,000 gm, lack of antenatal care, male sex, operative vaginal delivery, prematurity and multiple pregnancy were significantly associated with early neonatal deaths. Birth asphyxia was found to be the most important cause of death, followed by hyaline membrane disease and congenital malformations. Majority of the asphyxia related deaths were due to late intrapartum referral of the mothers. Forty-two per cent of early neonatal deaths occurred in babies weighing less than 1,500 gm. Early identification and referral of high risk mothers and health education would significantly reduce the early neonatal deaths.     

Determining causes of mortality in children enrolled in a vaccine field trial in a rural area in the Western Cape Province of South Africa

AIM: A mortality surveillance system was developed to identify and document causes of death among children enrolled in a tuberculosis vaccine field trial in South Africa. The aims of this study were to describe causes of mortality in children enrolled in a phase IV trial comparing intradermal with percutaneous administration of Bacille Calmette Guerin, and to compare causes of mortality recorded on death certificates with those obtained by clinical record review combined with verbal autopsies (CR/VA). METHODS: For children who died, certified causes of death were compared with those determined by CR/VA. RESULTS: Among 11677 children enrolled, 177 deaths were notified over 4 years. The incidence rate of death was 6.8/1000 person-years. Follow-up time ranged from 0.03 to 35.3 months (median 4 months; interquartile range 1.4-8.5). The infant mortality rate was 12.5/1000 live births and the neonatal mortality was 3/1000 live births. Pneumonia, gastroenteritis and septicaemia were among top causes of mortality by both methods. 'Sudden unexplained' and 'ill-defined' causes were among top causes of mortality based on CR/VA, while tuberculosis and 'natural causes' were among top causes based on death certificates. Important underlying causes of mortality by CR/VA include HIV/AIDS, prematurity/low birth weight and malnutrition. In 47% of deaths there was agreement on immediate causes of death. This increased to 54% when 'natural causes' and 'sudden unexplained deaths' were included. CONCLUSION: In this cohort mortality was largely due to infectious diseases. While CR/VA provided additional information on most deaths, this was not always sufficient to assign specific causes of death.     

Maternal socioeconomic characteristics and infant mortality from injuries in the Czech Republic 1989–92

OBJECTIVES: Infant and childhood mortality from injuries in Central and Eastern Europe is high but little is known about its determinants. This study examined whether maternal socioeconomic characteristics predict infant mortality from injuries in the Czech Republic. METHODS: Data on all live births registered in the Czech Republic 1989-91 (n=387 496) were linked with the national death register, 1989-92, using the unique national identification number. Effects of maternal socioeconomic characteristics, birth weight and gestational age, recorded in the birth register, on the risk of death from external causes (ICD-9 800-999) were estimated using logistic regression. RESULTS: Of the 195 linked infant deaths from external causes (rate 50/100000 live births), 73% were from suffocation. After controlling for other factors, the risk of death was higher in boys, declined with increasing maternal education (odds ratio for primary v university education 3.5, 95% confidence interval 1.5 to 8.6), maternal age, birth weight and gestational age, and was increased in infants of unmarried mothers and of mothers with higher parity. The effect of education appeared stronger in married mothers and in mothers of low parity. CONCLUSION: The risk of infant death from external causes in this population was strongly associated with maternal and family characteristics.     

Risk factors for neonatal death in Recife: a case-control study

OBJECTIVE: Neonatal mortality is the main cause of infant mortality in the city of Recife. The objective of the present study was to determine the major risk factors for neonatal death in Recife in 1995. METHODS: This is a case control study. Information was obtained from the mortality and live birth databases after validation of the data set, between January and December 1995. A sample of 456 cases and 2,280 controls was obtained after using the linkage technique between the two data sets. The difference in proportion was analyzed by the chi square test. The odds ratio was calculated as a risk measure, with a 95% confidence interval. The logistic regression technique was used to adjust potential confounding factors. RESULTS: 212 deaths (46.6%) occurred in the first 24 hours of life. We found that 358 (79.7%) of the cases presented low birth weight, with a 46-fold higher risk of death (CI =33.8-59.0 P<0.001) than those weighing >/= 2,500g. The major risk factors observed in the logistic regression analyses of the measure, listed in descending order, were: birth weight < 1,500g (OR= 49.6 CI= 22.6-108.7 P<0.001), 5-minute Apgar score < 7 (OR = 44.1 CI= 25.1-77.2 P<0.001), birth weight between 1,500 and 2,500g (OR= 8.2 CI= 4.8-14.0 P<0.001), gestational age < 37 weeks (OR= 4.3 CI= 2.6-7.1 P<0.001). CONCLUSIONS: Among the studied variables, birth weight, gestational age, and Apgar score should be considered the main risk factors for the surveillance of neonatal death.     

Ethnic differences in incidence of sudden infant death syndrome in Birmingham.

Among the 45,204 live births in Birmingham in the three calendar years 1981-3, there were 218 postneonatal deaths, giving a postneonatal mortality rate of 4.82 per 1000 live births. Postneonatal mortality rates were 4.22 for whites, 5.91 for Asians (relative risk 1.26, 95% confidence interval (CI) 1.04 to 1.53) and 8.20 for Afro-Caribbeans (relative risk 1.78, 95% CI 1.25 to 2.55). Among Asians malformations were common (3.36) and sudden infant death syndrome rare (1.18), in contrast to Afro-Caribbeans among whom the rates were 0.66 and 5.25, respectively. Logistic regression analysis demonstrated a significantly lower risk of sudden infant death syndrome (SIDS) in Asians and significantly raised risks of SIDS in very low birthweight babies and those with unemployed parent(s). Ethnic differences persisted after controlling for maternal age, social class, and birth weight. Studies of sociocultural differences in child rearing practices are needed and may uncover important aetiological factors of sudden infant death syndrome.     

Risk of sudden infant death syndrome in subsequent siblings

To determine the risk of recurrence of sudden infant death syndrome in families, we studied 251,124 live births by linked birth and death certificates from Oregon for a 10-year period. We found five recurrences among 385 subsequent siblings, for a rate of 13/1000 live births and a relative risk of 6. When the recurrences were adjusted separately for birth order and maternal age, the risk was still five times that expected (p less than 0.001). Families with infant deaths from causes other than sudden infant death syndrome had similar recurrence rates, suggesting that the phenomenon was not specific to sudden infant death syndrome. The overall mortality rate for subsequent siblings after a sudden death event totaled 20.8/1000. We believe that a risk of 2%, although small in the design of studies of infants at risk for sudden infant death syndrome, is not trivial in the counseling of parents.     

State reporting of live births of newborns weighing less than 500 grams: impact on neonatal mortality rates

The National Center for Health Statistics reports that in 1983 65% of all infant deaths in the United States occurred in the neonatal period. Of these reported neonatal deaths, 17% were of infants weighing less than 500 g at birth. There was, however, variation in state-reported incidence of live births of newborns in this weight cohort (0.2 to 2.2 per 1,000 live births). The states with the lowest neonatal mortality rate have the lowest incidence of birth weights less than 500 g (rho = .77). If it is assumed that mortality for this weight category is nearly 100%, there is marked variation (5% to 32%) in the contribution of this weight cohort to a state's total neonatal mortality rate. Contributing to this variation may be definitions of live birth used by states. The World Health Organization defines a live birth as the product of conception showing signs of life "irrespective of the duration of pregnancy" and this definition is used by 33 states. Only one state (Ohio) includes the gestational criteria of "at least 20 weeks" in its definition of live birth. There is evidence to suggest that definitions are not uniformly used within individual states. For example, in 1983, 20 states did not report any live births with weights less than 500 g among their "other" populations of nonwhite, nonblack residents. Half of these states, however, use the World Health Organization definition of live birth. Despite the exclusionary wording in Ohio's definition of liver birth, 16% of newborns who died in that state had birth weights less than 500 g.(ABSTRACT TRUNCATED AT 250 WORDS)     

Weight gain during pregnancy--a key factor in perinatal and infant mortality

OBJECTIVE: To identify risk factors for high perinatal (PMR) and infant (IMR) mortality in a rural area. DESIGN: In 49 randomly selected villages from two adjoining blocks of rural Varanasi, all pregnant women and live births were followed for perinatal and infant mortality, during the years 1988-1992. SUBJECTS: 6790 births and their 6649 live births. RESULTS: The PMR was 90.7 per thousand births and IMR was 98.6/1000 live births. These mortalities were significantly higher if weight gain during pregnancy was less than 7.0 kg. Low weight gain during pregnancy was also associated with significantly higher low birth weight deliveries and to some extent increased still birth rate. PMR and IMR decreased with higher levels of hemoglobin in third trimester and socioeconomic index; however, the calculated RR were not significant. CONCLUSION: Low weight gain during pregnancy is an important risk factor for PMR and IMR.     

Mortality patterns in breast versus artificially fed term babies in early infancy: a longitudinal study

The present study comprised 381 term babies weighing greater than 2.5 kg and 126 babies weighing less than or equal to 2.5 kg (low birth weight; LBW) at birth. A longitudinal follow up of 334 babies was done for 6 months. There were 273 'breast fed' babies and 234 'artificially fed' babies. Neonatal mortality rate per 1000 live births for term babies was 37.5, LBW had a rate of 31.5 while those weighing greater than 2.5 kg at birth a rate of 5.9; artificially fed had a mortality rate of 21.6 while breast fed had a low rate of 15.8. For 1-6 months period a mortality rate per 1000 live births of 53.8 was found for term babies, breast fed a rate of 23.9 while artificially fed a rate of 29.9; LBW had a rate of 44.9 while those weighing more than 2.5 kg at birth, a rate of 9. Low birth weight babies whether breast fed or artificially fed had significantly higher mortality than similarly fed babies weighing more than 2.5 kg at birth. Hence, mortality rate for term babies in early infancy can be reduced by simultaneous promotion of breastfeeding and prevention of low birth weight as it was dependent on both variables in this study.     

Triplets and higher-order multiple births. Time trends and infant mortality.

OBJECTIVES--To describe changes in rates of higher-order multiple births (triplets and higher) between 1972 and 1989, to compare infant mortality rates in infants of higher-order multiple births and singletons born from 1983 through 1985, and to compare infant mortality rates among higher-order multiples born from 1983 through 1985 with rates among those born in 1960. RESEARCH DESIGN--Population-based analysis of live births (1972 through 1989) and infant deaths (1960 and 1983 through 1985) in the United States. The rate of higher-order multiple births was calculated per 100,000 live births. DATA SOURCE--Computerized national natality files for 1972 through 1989 and national linked birth/infant death data sets for 1960 and 1983 through 1985 from the National Center for Health Statistics, Centers for Disease Control. POPULATION--Live births to white and black women in the United States. INTERVENTIONS--None. MAIN RESULTS--Between 1972 through 1974 and 1985 through 1989 the rate of higher-order multiple births increased by 113% among infants of white mothers and by 22% among infants of black mothers. In whites the increase was mostly age specific and was not due to the upward shift in the maternal age distribution. The increase was particularly large in white women aged 30 through 34 years (152%) and 35 through 39 years (165%) and in more highly educated mothers. In blacks the modest increase in the rate of higher-order multiple births was mostly due to an upward shift in the maternal age distribution. From 1983 through 1985, mortality of infants of higher-order multiple births was about 15 times that of singletons. This was due almost entirely to the lower birth weight distribution of infants of higher-order multiple births. Their weight-specific mortality compared favorably with that of singletons. At 500 through 999 g, mortality was about the same. In weight categories between 1000 and 1999 g, mortality rates in higher-order multiple births were much lower: weight-specific relative risks ranged from 0.30 to 0.73. Between 1960 and 1983 through 1985 infant mortality in higher-order multiple births declined by about 50%. CONCLUSIONS--It is likely that much of the increase in the incidence of higher-order multiple births is due to the rise in the use of ovulation-inducing drugs for the treatment of infertility. This increase and the decline in mortality risk have created a much greater need for medical and social services for infants of higher-order multiple births and their families.     

Causes of neonatal death: results from NeoKIP community-based trial in Quang Ninh province, Vietnam

Aim: To ascertain the causes of neonatal death in a province in northern Vietnam and analyse their distribution over age at death, birth weight and place of delivery. Methods: Verbal autopsy interviews using a questionnaire derived from WHO standard and adapted to Vietnamese conditions was performed on all neonatal deaths occurring in Quang Ninh province from July 2008 to June 2010. Three experienced paediatricians independently reviewed all verbal autopsy records (233) and assigned a main cause of death. In case of disagreement in the allocation of cause of death, a consensus process was initiated to decide on a final cause. Results: Neonatal mortality rate within the study area was 16/1000 (238 neonatal deaths and 14 453 live births) over the study period. Prematurity/low birth‐weight (37.8%), intrapartum‐related neonatal deaths (birth asphyxia, 33.2%), infections (13.0%) and congenital malformation (6.7%) were the four leading causes of death. Four cases of neonatal tetanus were found. Intrapartum‐related deaths dominated in the home delivery group, whereas prematurity was the most prominent cause of death at all facility levels. Most neonatal deaths occurred within the first 24 h after delivery (58.6%). Conclusion: A high proportion of deaths due to prematurity and intrapartum‐related causes, calls for improvements of delivery care and resuscitation practices at health facilities.     

Neonatal vital statistics: a 5-year review in Saudi Arabia

Neonatal mortality and causes of death at King Fahd Hospital of the University in Al Khobar, Saudi Arabia from June 1981 to May 1986 were analysed. The overall neonatal mortality rate declined from 15.6 to 8.1/1000 live births (LB), and after excluding lethal malformations mortality fell from 14.0 to 5.6/1000 LB. The reduction in mortality was most marked in infants weighing 1500 g or less, among whom mortality fell from 92.3 to 33% (P less than 0.001) during the 5-year period. Further, when annual variation in the very low birthweight rate was eliminated, a reduction in the mortality risk ratio from 1.47 to 0.81 was demonstrated. These significant reductions in mortality appear to be related to the establishment of neonatal intensive care. Major identified causes of death amenable to modern perinatal care were hyaline membrane disease, birth asphyxia, meconium aspiration and septicaemia.     

Causes of early neonatal mortality.

The early neonatal period extends up to the 7th day of the infant's life. 75% of infant deaths occur within the first 28 days of life, and most of them occur within the first 7 days. In a retrospective study undertaken from June 1, 1987, to May 31, 1990, data was obtained from the Neonatal Care Section of Krishna Hospital, Karad, District Satara, in south western Maharashtra. Most of the villagers wee of low socioeconomic status, and the women had poor educational level. Most of the deliveries in this area are conducted by untrained dais under unhygienic conditions. The early neonatal mortality rate (ENMR) was defined as neonatal death of babies weighing over 1000 g during the first 7 days per 1000 live births. A total of 1013 live births with weight more than 1000 g were included in the study: 533 wee males and 480 females. The incidence of low-birth-weight (=or- 2.5 kg) babies was 77.1%, and that of prematurity (gestational age 37 weeks) was 58.9%. There were 37 neonatal deaths, with an ENMR of 36.6. The chief causes of ENMR were perinatal asphyxia (40.5%), prematurity (29.7%), bacterial infections (27.0%), and congenital malformations (2.8%). The mortality was higher in low-birth-weight as compared to the normal-birth-weight babies. A total of 59% of all births were preterms who contributed to 29.7% of deaths. The high incidence of low-birth-weight babies was attributable to the fact that this hospital received 79.4% of total admissions for delivery of complicated pregnancy referrals from the peripheries. The difference between mortality of babies with birth weight of less than and more than 2.5 kg was statistically significant (p0.05). Regular antenatal checkups, health education of pregnant and lactating mothers, professional child delivery, and timely referral of pregnancy complications to well-equipped hospitals may cut down on early neonatal mortality.     

Perinatal factors and adverse outcome in extremely low birthweight infants.

Perinatal factors associated with death or disability at 2 years were identified in an inborn cohort of 196 live births with a birth weight of 500-999 g. Antepartum haemorrhage, multiple pregnancy, breech presentation, perinatal asphyxia, hypothermia on admission, hyaline membrane disease, persistent pulmonary hypertension, severe respiratory failure, and intraventricular haemorrhage were associated with increased mortality. Factors associated with increased survival included maternal hypertension, caesarean birth, increasing maturity or size at birth, female sex, and fetal growth retardation. Stepwise multiple discriminant function analysis showed that six factors correctly classified the outcome in 83% of infants: intraventricular haemorrhage was the most important factor followed by the presence of acidosis and hypoxia in the early neonatal period, birth weight, pre-eclamptic toxaemia, and caesarean birth. This study also showed that intraventricular haemorrhage, seizures, antepartum haemorrhage and delay in regaining birth weight were associated with increased disability among survivors.     

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.     

Sudden infant death syndrome and infant mortality in Aboriginal and non-Aboriginal infants

The aim of this study was to investigate sudden infant death syndrome (SIDS) in the context of total infant mortality for Aboriginal and non-Aboriginal infants. Deaths for infants born in Western Australia from 1980 to 1988 inclusive were ascertained from a total population data base. Infant mortality rates and rates by period and cause of death were calculated for both populations. Aboriginal infants had a mortality rate three times that for non-Aboriginal infants (23.6 cf. 7.9 per 1000 live births) and both populations showed a similar rate of decline in mortality over the study period. There were differences in the proportion of deaths occurring neonatally and postneonatally in the two populations. In terms of SIDS, 21% of the deaths in Aboriginal infants occurred neonatally compared with 7% for non-Aboriginal infants. The overall cause of infant death distribution differed significantly between the two populations ( P < 0.001). During the study period, Aboriginal infants showed a significant increase in deaths due to SIDS and a significant decrease in those due to birth defects and low birthweight. These results suggest it would be useful to review the pathology and diagnosis of sudden unexplained death in infancy.     

Perinatal and postneonatal mortality in England and Wales among immigrants from the Indian subcontinent

Perinatal and postneonatal mortality among immigrants to England and Wales from India, Pakistan and Bangladesh (Asians) for the years 1982–85 showed significant differences not only between the immigrant and indigenous populations, but also among the different groups from the Indian subcontinent. Compared with the perinatal mortality rate of 10.1 per 1000 total births in UK born mothers, rates in infants of mothers born in India, Bangladesh, and Pakistan were 12.5, 14.3 and 18.8 respectively. In contrast, postneonatal mortality in infants of Indian and Bangladeshi origin (3.9 and 2.8 per 1000 live births respectively) was lower than in the indigenous population (4.1), with Pakistani infants experiencing the highest rate (6.4). Excess perinatal mortality in infants of Asian origin was apparent at most maternal ages and parities. Pakistani infants had the highest rates of perinatal and postneonatal mortality in all age, parity and birth weight groups. The Asian groups showed higher mortality from congenital anomalies in both the perinatal and the postneonatal period, the rates in Pakistani infants being almost double those in Indian and Bangaladeshi infants. A significant finding was the lower rates of sudden infant death in all the groups of Asian origin.