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

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

Perinatal mortality attributable to complications of childbirth in Matlab, Bangladesh

Very few population-based studies of perinatal mortality in developing countries have examined the role of intrapartum risk factors. In the present study, the proportion of perinatal deaths that are attributable to complications during childbirth in Matlab, Bangladesh, was assessed using community-based data from a home-based programme led by professional midwives between 1987 and 1993. Complications during labour and delivery--such as prolonged or obstructed labour, abnormal fetal position, and hypertensive diseases of pregnancy--increased the risk of perinatal mortality fivefold and accounted for 30% of perinatal deaths. Premature labour, which occurred in 20% of pregnancies, accounted for 27% of perinatal mortality. Better care by qualified staff during delivery and improved care of newborns should substantially reduce perinatal mortality in this study population.     

Levels and risk factors for perinatal mortality in Ahmedabad, India

To estimate levels and determinants of perinatal mortality, we conducted a hospital-based surveillance and case-control study, linked with a population survey, in Ahmedabad, India. The perinatal mortality rate was 79.0 per 1000, and was highest for preterm low-birth-weight babies. The case-control study of 451 stillbirths, 160 early neonatal deaths and 1465 controls showed that poor maternal nutritional status, absence of antenatal care, and complications during labour were independently associated with substantially increased risks of perinatal death. Multivariate analyses indicate that socioeconomic factors largely operate through these proximate factors and do not have an independent effect. Estimates of attributable risk derived from the prevalence of exposures in the population survey suggest that improvements in maternal nutrition and antenatal and intrapartum care could result in marked reductions of perinatal mortality.     

Perinatal mortality in rural Malawi.

Reported are the results of a study to assess the prevalence and risk factors for perinatal death among pregnant women in Malawi over the period 1987-90. There were 264 perinatal deaths among the 3866 women with singleton pregnancies (perinatal mortality rate, 68.3 per 1000 births). Among the risk factors for perinatal mortality were the following: reactive syphilis serology, nulliparity, a late fetal or neonatal death in the most recent previous birth, maternal height < 150 cm, home delivery, and low socioeconomic status. Although unexplained perinatal deaths will continue to occur, perinatal mortality can be reduced if its causes and risk factors in a community are given priority in antenatal and intrapartum care programmes. The following interventions could potentially reduce the perinatal mortality in the study population: screening and treating women with reactive syphilis serology; and management from early labour, by competent personnel in a health facility, of nulliparous women and multiparous women who are short or have a history of a perinatal death.     

Community-based prevention of perinatal deaths: lessons from nineteenth-century Sweden

BACKGROUND: Perinatal deaths have been more difficult to prevent than infant deaths in low- income countries due to its close relation to poor maternal outcome. The aim of the study was to perform a comprehensive population-based analysis of perinatal mortality in a high mortality setting and to determine the impact of midwifery-assisted home deliveries. METHOD: The study design was a community-based cohort study. In all, 4876 perinatal deaths were recorded among 116 211 newborns in the districts of Sundsvall and Skelleftea in northern Sweden during the years 1831-1899. Relative risks, 95% CI, population attributable proportions and prevented fractions were calculated. RESULTS: The overall perinatal mortality rate was 42.0 per 1000 births. A previous stillbirth represented one of the most important risk factors (RR = 3.25, 95% CI : 2.97-3.56), with a population attributable proportion of 7%. Two or more previous stillbirths gave an RR of 8.50 (95% CI : 7.58-9.53) and a population attributable proportion of 4%. There was an increased risk of perinatal mortality for mothers over 35 years old, the primiparous and the unmarried, while grandparous women had a higher perinatal mortality that was accounted for completely by a poor history of previous stillbirths and infant deaths among these women. The children of crofters, farmers and workers had higher perinatal mortality, but area had no significant impact. During the years 1881-1890 and 1891-1899, the prevented fractions of midwifery were 15% and 32%, respectively. CONCLUSION: Poor reproductive history, particularly previously high perinatal mortality, is associated with high perinatal mortality. Midwifery-assisted at home deliveries successfully reduced perinatal mortality.     

The importance of preterm births for peri- and neonatal mortality in rural Malawi

Peri- and neonatal mortality remain high in developing countries, especially in sub-Saharan Africa. In the present study, we quantified and identified the most important predictors of early mortality in rural Malawi. Data were obtained from a community-based cohort of 795 pregnant women and their 813 fetuses, followed prospectively from mid-pregnancy. In this group, peri- and neonatal mortality rates were 65.3 deaths per 1000 births and 37.0 deaths per 1000 live births respectively. When controlled for month of birth, maternal age and selected socio-economic variables, preterm birth was the strongest independent predictor of both peri- and neonatal mortality (adjusted odds ratios 9.6 for perinatal and 11.0 for neonatal mortality; 95% confidence intervals: [4.4, 21.0] and [3.7, 32.7] respectively). Weaker risk factors for mortality included a maternal history of stillbirth and abnormal delivery. Preterm delivery was associated with primiparity and peripheral malaria parasitaemia of the mother, and it accounted for 65% of the population-attributable risk for perinatal and 68% of the neonatal mortality. Successful intervention programmes to reduce peri- and neonatal mortality in Malawi have to include strategies to predict and prevent prematurity.     

Risk factors for perinatal deaths in rural Bangladesh

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

Perinatal mortality in Shanghai: 1986-1987.

The incidence of, and risk factors associated with, perinatal mortality in Shanghai during 1986-1987 are examined using data from a multi-site study conducted in 29 hospitals. The overall perinatal mortality rate was 14.96 per 1000 births. The mortality rates of antepartum fetal death, intrapartum fetal death and early neonatal death were 5.97, 2.06 and 6.94 per 1000 births, respectively. The perinatal mortality rates increased in winter and late spring. Male neonates were 1.5 times more likely to die than females. Low birthweight and preterm infants had 15 to 80 times higher risk of perinatal death. Higher parity, multiple pregnancy, and maternal age greater than or equal to 35 years were the risk factors for perinatal mortality. Asphyxia, cord complications, and congenital malformations were found to be the major causes of perinatal deaths. Comparison of mortality rates between Shanghai and the US suggests that the shortage of advanced technology in perinatal care (e.g. neonatal intensive care units) is a major obstacle to the reduction of perinatal mortality in Shanghai.     

Causes of perinatal mortality in an African city.

Little has been published about the causes of most of the deaths responsible for the high perinatal mortality rates characteristic of preindustrial, urban societies. The present study searched for answers in one such society by identifying the causes of death in a large-scale analysis of perinatal mortality in Addis Ababa, Ethiopia. A 72% autopsy rate was achieved when 1019 postmortem examinations were performed for 1424 consecutive perinatal deaths. The overall perinatal mortality rate was 65.3 per thousand live births. The ratio of stillbirths to neonatal deaths was 2.7:1, indicating that maternal factors were dominant in causing the deaths. One-third of the deaths were due to amniotic fluid infections, 15% to obstructed labour, 8% to abruptio placentae, and the rest to more than 20 other specific disorders.     

Can clinical risk factors for late stillbirth in West Africa be detected during antenatal care or only during labour?

BACKGROUND: Recent studies have shown that the most important risk factors for perinatal mortality in developing countries are not detectable during antenatal care but can be observed only shortly before or during labour. Although 60% of perinatal deaths in these countries are stillbirths, few epidemiological studies focus on them. We tested the hypothesis that the risk factors for late stillbirth in West Africa are detectable principally shortly before or during labour. METHODS: Data came from a prospective population-based study (the MOMA survey) that collected information about 20 326 pregnant women in seven areas, primarily urban, in West Africa. RESULTS: There were 19 870 singleton births. The stillbirth rate was 25.9 per 1000 total births (95% CI: 23.7-28.1). In the crude analysis, after adjustment and consideration of prevalence, the principal risk factors for late stillbirth were: late antenatal or intrapartum vaginal bleeding, intrapartum hypertension, dystocia, and infection. Other risk factors were: maternal height (<150 cm), maternal age (>35 years), previous stillbirths, hypertension at the 8-month antenatal visit and number of antenatal visits (<2). CONCLUSIONS: The principal risk factors for late stillbirth observed in our study could be detected only in the late antenatal and intrapartum period. These results highlight the potential benefits of partograph use. They need to be confirmed by studies incorporating continuous intrapartum fetal monitoring.     

Causes of stillbirths and early neonatal deaths: data from 7993 pregnancies in six developing countries

OBJECTIVE: To report stillbirth and early neonatal mortality and to quantify the relative importance of different primary obstetric causes of perinatal mortality in 171 perinatal deaths from 7993 pregnancies that ended after 28 weeks in nulliparous women. METHODS: A review of all stillbirths and early newborn deaths reported in the WHO calcium supplementation trial for the prevention of pre-eclampsia conducted at seven WHO collaborating centres in Argentina, Egypt, India, Peru, South Africa and Viet Nam. We used the Baird-Pattinson system to assign primary obstetric causes of death and classified causes of early neonatal death using the International classification of diseases and related health problems, Tenth revision (ICD-10). FINDINGS: Stillbirth rate was 12.5 per 1000 births and early neonatal mortality rate was 9.0 per 1000 live births. Spontaneous preterm delivery and hypertensive disorders were the most common obstetric events leading to perinatal deaths (28.7% and 23.6%, respectively). Prematurity was the main cause of early neonatal deaths (62%). CONCLUSIONS: Advancements in the care of premature infants and prevention of spontaneous preterm labour and hypertensive disorders of pregnancy could lead to a substantial decrease in perinatal mortality in hospital settings in developing countries.     

Temporal changes in the distribution of population risk factors attenuate the reduction in perinatal mortality

BACKGROUND AND OBJECTIVE: To examine and quantify the changing contribution of some risk factors to the perinatal mortality rate. METHODS: A population-based retrospective cohort study in Northern England compared stillbirth, neonatal, and perinatal mortality rates by birthweight, maternal age, plurality, and gender between 1982-1990 and 1991-2000. RESULTS: Atlhough the perinatal mortality rate fell by 20% between 1982-1990 and 1991-2000, the proportion of births in high risk groups (low and high birthweight, older mothers, and multiple births) increased. Standardizing the rates for 2000 to the risk factor distribution in 1982 resulted in lower rates. Changes in the birthweight distribution had the largest impact, particularly on neonatal mortality. Nearly a quarter of neonatal deaths in Northern England in 2000 can be attributed to the shift in the birthweight distribution since 1982, especially to the increase in low birthweight births. CONCLUSION: Changes in the distribution of birthweight, maternal age, and plurality over the study period attenuated the observed reduction in perinatal mortality. It is important to consider differences in the population prevalence of such risk factors to make valid geographic or temporal comparisons. Reasons for the secular shift in birthweight and the implications of any contributing change in obstetric practice require further investigation.     

In search for an explanation to the upsurge in infant mortality in Kenya during the 1988-2003 period

ABSTRACT: BACKGROUND: In Kenya, infant mortality rate increased from 59 deaths per 1000 live births in 1988 to 78 deaths per 1000 live births by 2003. This was an increase of about 32 percent in 15?years. The reasons behind this upturn are poorly understood. This paper investigates the probable factors behind the upsurge in infant mortality in Kenya during the 1988-2003 period. Understanding the causes behind the upsurge is critical in designing high impact public health strategies for the acceleration of national and international public health goals such as the Millennium Development Goals (MDGs). The reversals in early child mortality is also regarded as one of the most important topics in contemporary demography. METHODS: A merged dataset drawn from the Kenya Demographic and Health Surveys of 1993, 1998 and 2003 was used. The merged KDHS included a total of 5265 singletons. Permission to use the KDHS data was obtained from ICF international on the following website: http://www.measuredhs.com. Stata version 11.0 was used for data analysis. The paper used regression decomposition techniques as the main method for analysing the contribution of the selected covariates on the upsurge in infant mortality. RESULTS: The duration of breastfeeding; maternal education, regional HIV prevalence and malaria endemicity were the factors that appeared to have contributed much to the observed rise in infant mortality in Kenya over the period. If all the live births that occurred in the 1996/03 period had the same mean values of all explanatory variables as those of live births that occurred in the 1988/95 period, then infant mortality would have increased by a massive 14 deaths per 1000 live births. However, if the live births that occurred in the 1988/95 period had the same mean values of all explanatory variables as those that occurred in the 1996/03 period, the upsurge in infant mortality would have been negligible. While the role of HIV in the upturn in infant mortality in Kenya and other sub Saharan African countries is indisputable, this study demonstrates that it is the duration of breastfeeding and Malaria endemicity that played a more significant role in Kenya's upsurge in infant mortality during the 1988-2003 period. CONCLUSIONS: Efforts aimed at controlling and preventing malaria and HIV should be stepped up to avert an upsurge in infant mortality. There is need to step up alternative baby feeding practices among mothers who are HIV positive especially after the first six months of breastfeeding. Owing to the widely known inverse relationship between maternal education and infant mortality, there is need for concerted efforts to promote girl child education. Owing to the important role played by the short preceding birth interval to the upsurge in infant mortality, there is need to promote family planning methods in Kenya.     

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

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

Challenge of reducing perinatal mortality in rural Congo: findings of a prospective, population-based study

Each year, an estimated six million perinatal deaths occur worldwide, and 98% of these deaths occur in low- and middle-income countries. These estimates are based on surveys in both urban and rural areas, and they may underrepresent the problem in rural areas. This study was conducted to quantify perinatal mortality, to identify the associated risk factors, and to determine the most common causes of early neonatal death in a rural area of the Democratic Republic of the Congo (DRC). Data were collected on 1,892 births. Risk factors associated with perinatal deaths were identified using multivariate analysis with logistic regression models. Causes of early neonatal deaths were determined by physician-review of information describing death. The perinatal mortality rate was 61 per 1,000 births; the stillbirth rate was 30 per 1,000 births; and the early neonatal death rate was 32 per 1,000 livebirths. Clinically-relevant factors independently associated with perinatal death included: low birthweight [odds ratio (OR)=13.51, 95% confidence interval (CI) 7.82-23.35], breech presentation (OR)=12.41; 95% CI 4.62-33.33), lack of prenatal care (OR=2.70, 95% CI 1.81-4.02), and parity greater than 4 (OR=1.93 95% CI 1.11-3.37). Over one-half of early neonatal deaths (n=37) occurred during the first two postnatal days, and the most common causes were low birthweight/prematurity (47%), asphyxia (34%), and infection (8%). The high perinatal mortality rate in rural communities in the DRC, approximately one-half of which is attributable to early neonatal death, may be modifiable. Specifically, deaths due to breech presentation, the second most common risk factor, may be reduced by making available emergency obstetric care. Most neonatal deaths occur soon after birth, and nearly three-quarters are caused by low birthweight/prematurity or asphyxia. Neonatal mortality might be reduced by targeting interventions to improve neonatal resuscitation and care of larger preterm infants.     

An analysis of anemia and pregnancy-related maternal mortality

The relationship of anemia as a risk factor for maternal mortality was analyzed by using cross-sectional, longitudinal and case-control studies because randomized trials were not available for analysis. The following six methods of estimation of mortality risk were adopted: 1) the correlation of maternal mortality rates with maternal anemia prevalence derived from national statistics; 2) the proportion of maternal deaths attributable to anemia; 3) the proportion of anemic women who die; 4) population-attributable risk of maternal mortality due to anemia; 5) adolescence as a risk factor for anemia-related mortality; and 6) causes of anemia associated with maternal mortality. The average estimates for all-cause anemia attributable mortality (both direct and indirect) were 6.37, 7.26 and 3.0% for Africa, Asia and Latin America, respectively. Case fatality rates, mainly for hospital studies, varied from <1% to >50%. The relative risk of mortality associated with moderate anemia (hemoglobin 40-80 g/L) was 1.35 [95% confidence interval (CI): 0.92-2.00] and for severe anemia (<47 g/L) was 3.51 (95% CI: 2.05-6.00). Population-attributable risk estimates can be defended on the basis of the strong association between severe anemia and maternal mortality but not for mild or moderate anemia. In holoendemic malarious areas with a 5% severe anemia prevalence (hemoglobin <70 g/L), it was estimated that in primigravidae, there would be 9 severe-malaria anemia-related deaths and 41 nonmalarial anemia-related deaths (mostly nutritional) per 100,000 live births. The iron deficiency component of these is unknown.     

Are there gaps in the provision of perinatal care in Greece?

STUDY OBJECTIVE: The objective was to test the hypothesis that easy access to sophisticated hospitals is associated with a reduction in perinatal mortality. DESIGN: The study was a nationwide questionnaire survey of a birth cohort. SUBJECTS: All deliveries greater than 500g weight of singleton live births and stillbirths occurring throughout Greece during April 1983 were included. Completed questionnaires were returned for 10,953 deliveries (8% of total annual registered births in Greece), and data on 10,790 singleton births were analysed, including 127 stillbirths and 137 early neonatal deaths. MEASUREMENTS AND MAIN RESULTS: The questionnaires contained information on demographic characteristics of each parent, mother's reproductive history, and clinical course of pregnancy, labour and perinatal period. Mothers living in big urban centres were compared with the rest of the country. Overall mortality rates were similar but births in the big urban centres were of significantly lower weight due to fetal growth retardation. Logistic regression analysis, taking account of birthweight, parity, maternal age, and maternal education showed that there was an advantage to mothers living in big urban centres, perinatal mortality being 63% higher in the rest of the country (chi 2 = 7.4, p less than 0.01). CONCLUSION: The evidence obtained supports the original hypothesis and suggest that a reduction in the high perinatal mortality rate in Greece may be achieved by restructuring the perinatal services.     

Maternal and perinatal health status in the State of S?o Paulo, Brazil

The assistance offered during pregnancy and labour as also to the newborn child, and its relationship to maternal and perinatal mortality in the State of S. Paulo in 1984, is analysed on the basis of official available data. With respect to prenatal care the number of visits per woman was considered to be "sufficient" though of doubtful quality. The proportion of cesarean sections was very high (46.2%). Maternal mortality was found to be 4.86 deaths per 10,000 live births, but despite its being high, this figure is certainly too low and the correct figure is probably twice as high. The principal cause of maternal deaths is toxemia in pregnancy, followed by hemorrhage and abortion. Most of these deaths could have been avoided with care during pregnancy and labour. The rate of perinatal mortality was found to be 29.2 deaths per thousand births in 1984. This figure is also very high. The analysis of the causes of death for this period showed that the disorders which arose during the perinatal period were responsible for 90 per cent of the total number of deaths. The main causes of death in this group were the intra-uterine hypoxias and anoxias, asphyxia, respiratory distress syndrome and massive aspiration syndrome. These data bring to light the poor quality of the care offered to this group. The authors trust that the new policy of the Decentralized and Unified System of Health will take the quality of care as much as the integration of services into consideration with a view to overcoming the precarious maternal and perinatal health situation in S. Paulo.     

广州市海珠区围产儿死亡原因分析

目的探讨围产儿死亡原因,以降低围产儿死亡率。方法将1999年~2004年广州市海珠区围产儿死亡原因进行分析。结果共483例围产儿死亡,死亡原因主要集中在畸形(36.65%),母体因素(20.50%)、脐带因素(13.87%)、特发性早产(11.59%)、胎盘因素(7.87%)、新生儿因素(6.00%)、窒息(2.69%)及其他(0.83%)。结论加强围产儿保健,28周前发现畸形、预防早产、治疗妊娠合并症、加强监护有助于减少围产儿死亡的发生。     

Maternal malaria and perinatal HIV transmission, western Kenya

To determine whether maternal placental malaria is associated with an increased risk for perinatal mother-to-child HIV transmission (MTCT), we studied HIV-positive women in western Kenya. We enrolled 512 mother-infant pairs; 128 (25.0%) women had placental malaria, and 102 (19.9%) infants acquired HIV perinatally. Log10 HIV viral load and episiotomy or perineal tear were associated with increased perinatal HIV transmission, whereas low-density placental malaria (<10,000 parasites/mL) was associated with reduced risk (adjusted relative risk [ARR] 0.4). Among women dually infected with malaria and HIV, high-density placental malaria (>10,000 parasites/mL) was associated with increased risk for perinatal MTCT (ARR 2.0), compared to low-density malaria. The interaction between placental malaria and MTCT appears to be variable and complex: placental malaria that is controlled at low density may cause an increase in broad-based immune responses that protect against MTCT; uncontrolled, high-density malaria may simultaneously disrupt placental architecture and generate substantial antigen stimulus to HIV replication and increase risk for MTCT.