The project to understand and research preterm pregnancy outcomes and stillbirths in South Asia (PURPOSe): a protocol of a prospective,cohort study of causes of mortality among preterm births and stillbirths

Background

In South Asia, where most stillbirths and neonatal deaths occur, much remains unknown about the causes of these deaths. About one-third of neonatal deaths are attributed to prematurity, yet the specific conditions which cause these deaths are often unclear as is the etiology of stillbirths. In low-resource settings, most women are not routinely tested for infections and autopsy is rare.

Methods

This prospective, cohort study will be conducted in hospitals in Davengere, India and Karachi, Pakistan. All women who deliver either a stillbirth or a preterm birth at one of the hospitals will be eligible for enrollment. With consent, the participant and, when applicable, her offspring, will be followed to 28-days post-delivery. A series of research tests will be conducted to determine infection and presence of other conditions which may contribute to the death. In addition, all routine clinical investigations will be documented. For both stillbirths and preterm neonates who die ≤ 28 days, with consent, a standard autopsy as well as minimally invasive tissue sampling will be conducted. Finally, an expert panel will review all available data for stillbirths and neonatal deaths to determine the primary and contributing causes of death using pre-specified guidance.

Conclusion

This will be among the first studies to prospectively obtain detailed information on causes of stillbirth and preterm neonatal death in low-resource settings in Asia. Determining the primary causes of death will be important to inform strategies most likely to reduce the high mortality rates in South Asia.

Trial registration

Clinicaltrials.gov (NCT03438110) Clinical Trial Registry of India (CTRI/2018/03/012281).

     

Incidence of stillbirth and perinatal mortality and their associated factors among women delivering at Harare Maternity Hospital, Zimbabwe: a cross-sectional retrospective analysis

BACKGROUND: Death of an infant in utero or at birth has always been a devastating experience for the mother and of concern in clinical practice. Infant mortality remains a challenge in the care of pregnant women worldwide, but particularly for developing countries and the need to understand contributory factors is crucial for addressing appropriate perinatal health. METHODS: Using information available in obstetric records for all deliveries (17,072 births) at Harare Maternity Hospital, Zimbabwe, we conducted a cross-sectional retrospective analysis of a one-year data, (1997-1998) to assess demographic and obstetric risk factors for stillbirth and early neonatal death. We estimated risk of stillbirth and early neonatal death for each potential risk factor. RESULTS: The annual frequency of stillbirth was 56 per 1,000 total births. Women delivering stillbirths and early neonatal deaths were less likely to receive prenatal care (adjusted relative risk [RR] = 2.54; 95% confidence intervals [CI] 2.19-2.94 and RR = 2.52; 95% CI 1.63-3.91), which for combined stillbirths and early neonatal deaths increased with increasing gestational age (Hazard Ratio [HR] = 3.98, HR = 7.49 at 28 and 40 weeks of gestation, respectively). Rural residence was associated with risk of infant dying in utero, (RR = 1.33; 95% CI 1.12-1.59), and the risk of death increased with increasing gestational age (HR = 1.04, HR = 1.69, at 28 and 40 weeks of gestation, respectively). Older maternal age was associated with risk of death (HR = 1.50; 95% CI 1.21-1.84). Stillbirths were less likely to be delivered by Cesarean section (RR = 0.64; 95% CI 0.51-0.79), but more likely to be delivered as breech (RR = 4.65; 95% CI 3.88-5.57, as were early neonatal deaths (RR = 3.38; 95% CI 1.64-6.96). CONCLUSION: The frequency of stillbirth, especially macerated, is high, 27 per 1000 total births. Early prenatal care could help reduce perinatal death linking the woman to the health care system, increasing the probability that she would seek timely emergency care that would reduce the likelihood of death of her infant in utero. Improved quality of obstetric care during labor and delivery may help reduce the number of fresh stillbirths and early neonatal deaths.     

Stillbirths and neonatal deaths in appropriate, small and large birthweight for gestational age fetuses

AIMS: To compare the risk of stillbirth and neonatal death in small-for-gestational-age (SGA), appropriate-for-gestational-age (AGA) and large-for-gestational-age (LGA) fetuses and neonates. DESIGN: Retrospective analysis of 662 043 births and outcomes recorded in the Victorian Perinatal Data Collection Unit (1992-2002). INCLUSION CRITERIA: Births in Victoria in 1992-2002. EXCLUSION CRITERIA: Multiple pregnancy and congenital birth defects. MAIN OUTCOME MEASURES: Births, stillbirths and neonatal deaths at each week of gestation after 23 weeks were stratified by birthweight into appropriate, small and large for gestational age. Stillbirth risk per 1000 ongoing pregnancies and neonatal death rate per 1000 live births were calculated. RESULTS: For the AGA group, the overall stillbirth risk was 2.88 per 1000 and neonatal death rate was 1.35 per 1000. In the LGA group, these were 2.62 and 1.83 per 1000, respectively. The slight increase in neonatal death rate among LGA fetuses was confined to those delivered after 28 weeks gestation. In the SGA group, the stillbirth risk and neonatal death rate were 15.1 and 3.99 per 1000, respectively. CONCLUSION: The risk of stillbirth per week of gestational age and neonatal death rates do not differ significantly between AGA and LGA fetuses and neonates. The SGA fetus is at significantly greater risk of both stillbirth and neonatal death, particularly with advancing gestational age.     

Adverse perinatal outcomes among interracial couples in the United States

OBJECTIVE: We examined the association between parental race and stillbirth and adverse perinatal and infant outcomes. METHODS: We conducted a retrospective cohort analysis using the 1995-2001 linked birth and infant death files that are composed of live births and fetal and infant deaths in the United States. The study included singleton births delivered at 20 or more weeks of gestation with a fetus weighing 500 g or more (N = 21,005,786). Parental race was categorized as mother white-father white, mother white-father black, mother black-father white, and mother black-father black. Multivariable logistic regression analysis was performed to examine the association between parental race and risks of stillbirth (at > or = 20 weeks), small for gestational age (defined as birth weight < 5th and < 10th percentile for gestational age), and early neonatal (< 7 days), late neonatal (7-27 days), and postneonatal (28-364 days) mortality. All analyses were adjusted for the confounding effects of maternal age, education, trimester at which prenatal care began, parity, marital status, and smoking during pregnancy. RESULTS: Although risks varied across parental race categories, stillbirth was associated with a higher-than-expected risk for interracial couples: mother white-father black, relative risk (RR) 1.17 (95% confidence interval [CI] 1.10-1.26) and mother black-father white, RR 1.37 (95% CI 1.21-1.54) compared with mother white-father white parents. The RR for stillbirth was even higher among mother black-father black parents (RR 1.67, 95% CI 1.62-1.72). The overall patterns of association for small for gestational age births (< 5th and < 10th percentile) and early neonatal mortality were similar to those seen for stillbirth. CONCLUSION: There is an increased risk of adverse perinatal outcomes for interracial couples, including stillbirth, small for gestational age infants, and neonatal mortality. LEVEL OF EVIDENCE: II-2.     

Count every newborn: EN-BIRTH study improving facility-based coverage and quality measurement in routine information systems

Background

An estimated >2 million babies stillborn around the world each year lack visibility. Low- and middle-income countries carry 84% of the burden yet have the least data. Most births are now in facilities, hence routine register-recording presents an opportunity to improve counting of stillbirths, but research is limited, particularly regarding accuracy. This paper evaluates register-recorded measurement of hospital stillbirths, classification accuracy, and barriers and enablers to routine recording.

Methods

The EN-BIRTH mixed-methods, observational study took place in five hospitals in Bangladesh, Nepal and Tanzania (2017–2018). Clinical observers collected time-stamped data on perinatal care and birth outcomes as gold standard. To assess accuracy of routine register-recorded stillbirth rates, we compared birth outcomes recorded in labour ward registers to observation data. We calculated absolute rate differences and individual-level validation metrics (sensitivity, specificity, percent agreement). We assessed misclassification of stillbirths with neonatal deaths. To examine stillbirth appearance (fresh/macerated) as a proxy for timing of death, we compared appearance to observed timing of intrauterine death based on heart rate at admission.

Results

23,072 births were observed including 550 stillbirths. Register-recorded completeness of birth outcomes was > 90%. The observed study stillbirth rate ranged from 3.8 (95%CI = 2.0,7.0) to 50.3 (95%CI = 43.6,58.0)/1000 total births and was under-estimated in routine registers by 1.1 to 7.3 /1000 total births (register: observed ratio 0.9–0.7). Specificity of register-recorded birth outcomes was > 99% and sensitivity varied between hospitals, ranging from 77.7–86.1%. Percent agreement between observer-assessed birth outcome and register-recorded birth outcome was very high across all hospitals and all modes of birth (> 98%). Fresh or macerated stillbirth appearance was a poor proxy for timing of stillbirth. While there were similar numbers of stillbirths misclassified as neonatal deaths (17/430) and neonatal deaths misclassified as stillbirths (21/36), neonatal deaths were proportionately more likely to be misclassified as stillbirths (58.3% vs 4.0%). Enablers to more accurate register-recording of birth outcome included supervision and data use.

Conclusions

Our results show these routine registers accurately recorded stillbirths. Fresh/macerated appearance was a poor proxy for intrapartum stillbirths, hence more focus on measuring fetal heart rate is crucial to classification and importantly reduction in these preventable deaths.

     

The Maternal and Newborn Health Registry Study of the Global Network for Women's and Children's Health Research

ObjectiveTo implement a vital statistics registry system to register pregnant women and document birth outcomes in the Global Network for Women's and Children's Health Research sites in Asia, Africa, and Latin America.MethodsThe Global Network sites began a prospective population-based pregnancy registry to identify all pregnant women and record pregnancy outcomes up to 42 days post-delivery in more than 100 defined low-resource geographic areas (clusters). Pregnant women were registered during pregnancy, with 42-day maternal and neonatal follow-up recorded—including care received during the pregnancy and postpartum periods. Recorded outcomes included stillbirth, neonatal mortality, and maternal mortality rates.ResultsIn 2010, 72 848 pregnant women were enrolled and 6-week follow-up was obtained for 97.8%. Across sites, 40.7%, 24.8%, and 34.5% of births occurred in a hospital, health center, and home setting, respectively. The mean neonatal mortality rate was 23 per 1000 live births, ranging from 8.2 to 48.5 per 1000 live births. The mean stillbirth rate ranged from 13.7 to 54.4 per 1000 births.ConclusionThe registry is an ongoing study to assess the impact of interventions and trends regarding pregnancy outcomes and measures of care to inform public health.ClinicalTrial.gov Trial Registration: NCT01073475     

The influence of interpregnancy interval on the subsequent risk of stillbirth and early neonatal death

OBJECTIVE: To study whether interpregnancy interval is associated with increased risks of stillbirth and early neonatal death and whether this possible association is confounded by maternal characteristics and previous reproductive history. METHODS: In a Swedish nationwide study of 410,021 women's first and second singleton deliveries between 1983 and 1997, we investigated the influence of interpregnancy interval on the subsequent risks of stillbirth and early neonatal death. Odds ratios (ORs) with 95% confidence intervals (CIs) estimated using unconditional logistic regression were adjusted for maternal characteristics and previous pregnancy outcome categorized into stillbirth, early neonatal death, preterm, or small for gestational age delivery. RESULTS: Compared with interpregnancy intervals between 12 and 35 months, very short interpregnancy intervals (0-3 months) were, in the univariate analyses, associated with increased risks of stillbirth and early neonatal death (crude OR 1.9; 95% CI 1.3, 2.7; and 1.8; 1.2, 2.8, respectively). However, after adjusting for maternal characteristics and previous reproductive history, women with interpregnancy intervals of 0 to 3 months were not at increased risks of stillbirth (adjusted OR 1.3; 95% CI 0.8, 2.1) or early neonatal death (adjusted OR 0.9; 95% CI 0.5, 1.6). Women with interpregnancy intervals of 72 months and longer were at increased risk of stillbirth (adjusted OR 1.5; 95% CI 1.1, 2.1) and possibly early neonatal death (adjusted OR 1.3; 95% CI 0.9, 2.1). CONCLUSION: Short interpregnancy intervals appear not to be causally associated with increased risk of stillbirth and early neonatal death, whereas long interpregnancy intervals were associated with increased risk of stillbirth and possibly early neonatal death.     

Global report on preterm birth and stillbirth (1 of 7): definitions,description of the burden and opportunities to improve data

Introduction

This is the first of seven articles from a preterm birth and stillbirth report. Presented here is an overview of the burden, an assessment of the quality of current estimates, review of trends, and recommendations to improve data.

Preterm birth

Few countries have reliable national preterm birth prevalence data. Globally, an estimated 13 million babies are born before 37 completed weeks of gestation annually. Rates are generally highest in low- and middle-income countries, and increasing in some middle- and high-income countries, particularly the Americas. Preterm birth is the leading direct cause of neonatal death (27%); more than one million preterm newborns die annually. Preterm birth is also the dominant risk factor for neonatal mortality, particularly for deaths due to infections. Long-term impairment is an increasing issue.

Stillbirth

Stillbirths are currently not included in Millennium Development Goal tracking and remain invisible in global policies. For international comparisons, stillbirths include late fetal deaths weighing more than 1000g or occurring after 28 weeks gestation. Only about 2% of all stillbirths are counted through vital registration and global estimates are based on household surveys or modelling. Two global estimation exercises reached a similar estimate of around three million annually; 99% occur in low- and middle-income countries. One million stillbirths occur during birth. Global stillbirth cause-of-death estimates are impeded by multiple, complex classification systems.

Recommendations to improve data

(1) increase the capture and quality of pregnancy outcome data through household surveys, the main data source for countries with 75% of the global burden; (2) increase compliance with standard definitions of gestational age and stillbirth in routine data collection systems; (3) strengthen existing data collection mechanisms—especially vital registration and facility data—by instituting a standard death certificate for stillbirth and neonatal death linked to revised International Classification of Diseases coding; (4) validate a simple, standardized classification system for stillbirth cause-of-death; and (5) improve systems and tools to capture acute morbidity and long-term impairment outcomes following preterm birth.

Conclusion

Lack of adequate data hampers visibility, effective policies, and research. Immediate opportunities exist to improve data tracking and reduce the burden of preterm birth and stillbirth.

     

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.     

Clinical significance of amniotic fluid glucose concentration in polyhydramnios

Objective: To evaluate whether amniotic fluid glucose concentration can predict poor neonatal outcome in cases with polyhydramnios as an overall assessment. Methods: In this retrospective study, we have reviewed 42 consecutive pregnant women with singleton gestations complicated with polyhydramnios who gave birth at one tertiary care center between January 2003 and September 2010. Perinatal clinical findings were reviewed, and the neonatal outcome, such as livebirth or stillbirth and early neonatal death, was compared. A p value less than 0.05 was considered to be significant. Results: Thirteen of 42 neonates had a poor outcome, including stillbirth or early neonatal death. Multiple logistic regression analysis showed that amniotic fluid glucose (p?=?0.042) was significant factor influencing poor neonatal prognosis [odds ratio 0.66; 95% confidence interval 0.44–0.98]. Receiver operating characteristics curve and sensitivity and specificity curve showed that the optimal cut-off value of amniotic fluid glucose concentration for predicting poor neonatal outcome was 17?mg/dl. Conclusions: Amniotic glucose concentration less than 17?mg/dl and the presence of congenital heart anomaly were better predictors for a poor postnatal outcome in cases with polyhydramnios.     

Neonatal resuscitation from a global perspective

The majority of perinatal and neonatal mortality occurs in low-resource settings in low- and middle-income countries. Access and quality of care at delivery are major determinants of the health and survival of newborn infants. Availability of basic neonatal resuscitation care at birth has improved, but basic neonatal resuscitation at birth or high-quality care continues to be inaccessible in some settings, leading to persistently high perinatal and neonatal mortality. Low-resource settings of high-income countries and socially disadvantaged communities also suffer from inadequate access to quality perinatal healthcare. Quality improvement, implementation research, and innovation should focus on improving the quality of perinatal healthcare and perinatal and neonatal outcomes in low-resource settings. The current review presents an update on issues confronting universal availability of optimal resuscitation care at birth and provides an update on ongoing efforts to address them.     

Previous caesarean or vaginal delivery: Which mode is a greater risk of perinatal death at the second delivery?

OBJECTIVE: To compare the risk of perinatal death after previous caesarean versus previous vaginal delivery, and pre-labour repeat caesarean versus trial of labour after previous caesarean. STUDY DESIGN: Using the data of the Berlin Perinatal Registry from 1993 to 1999, 7556 second parous women with a previous caesarean delivery were compared with 55142 second parous women with a previous vaginal delivery, and those 1435 women with pre-labour repeat caesarean were compared with 6121 women with a trial of labour after previous caesarean delivery. The rates of perinatal death, stillbirth and intrapartum/neonatal death were analysed using multivariable logistic regression to adjust for confounding variables and obstetric history. RESULTS: A previous caesarean delivery was associated with a 40% excess risk of perinatal death and a 52% excess risk of stillbirth (p<0.05); the risk of intrapartum/neonatal death was not significantly increased. There were no significantly higher rates of intrapartum/neonatal death and of stillbirth in women trying a vaginal birth versus pre-labour repeat caesarean. But in most cases of antepartum death, labour was induced for that reason. CONCLUSION: Consulting women about caesarean delivery for maternal request, the increased risk of perinatal death in further pregnancies should be discussed. After a previous caesarean delivery, a careful screening for several risk factors is necessary before recommending a trial of labour.     

Obstetric outcomes subsequent to intrauterine death in the first pregnancy

Objective  To compare obstetric outcomes in the pregnancy subsequent to intrauterine death with that following live birth in first pregnancy.
Design  Retrospective cohort study.
Setting  Grampian region of Scotland, UK.
Population  All women who had their first and second deliveries in Grampian between 1976 and 2006.
Methods  All women delivering for the first time between 1976 and 2002 had follow up until 2006 to study their next pregnancy. Those women who had an intrauterine death in their first pregnancy formed the exposed cohort, while those who had a live birth formed the unexposed cohort.
Main outcome measures  Maternal and neonatal outcomes in the second pregnancy, including pre-eclampsia, placental abruption, induction of labour, instrumental delivery, caesarean delivery, malpresentation, prematurity, low birthweight and stillbirth.
Results  The exposed cohort ( n = 364) was at increased risk of pre-eclampsia (OR 3.1, 95% CI 1.7–5.7); placental abruption (OR 9.4, 95% CI 4.5–19.7); induction of labour (OR 3.2, 95% CI 2.4–4.2); instrumental delivery (OR 2.0, 95% CI 1.4–3.0); elective (OR 3.1, 95% CI 2–4.8) and emergency caesarean deliveries (OR 2.1, 95% CI 1.5–3.0); and prematurity (OR 2.8, 95% CI 1.9–4.2), low birthweight (OR 2.8, 95% CI 1.7–4.5) and malpresentation (OR 2.8, 95% CI 2.0–3.9) of the infant as compared with the unexposed cohort ( n = 33 715). The adjusted odds ratio for stillbirth was 1.2 and 95% CI 0.4–3.4.
Conclusion  While the majority of women with a previous stillbirth have a live birth in the subsequent pregnancy, they are a high-risk group with an increased incidence of adverse maternal and neonatal outcomes.     

ENC training reduces perinatal mortality in Karnataka,India

Objective: To evaluate the effect of World Health Organization Essential Newborn Care course and the American Academy of Pediatrics Neonatal Resuscitation Program training on perinatal mortality in rural India. Methods: This study was part of a multi-country prospective, community-based cluster randomized controlled trial. Birth, 7-day and 28-day neonatal outcomes for all women with pregnancies greater than 28 weeks in the 26 study communities in Karnataka, India were included. Mortality rates pre- and post-Essential Newborn Care training were collected prospectively and then communities randomized to either receive neonatal resuscitation or refresher newborn care training in the control clusters. Results: Consent was obtained on 99% of the 25,096 births. Perinatal mortality for infants ≥500 g decreased from 52 to 36/1000 after newborn care training (RR 0.7; 95% CI 0.5, 0.9); stillbirth decreased from 23 to 14/1000 (RR 0.62; 95% CI 0.46, 0.83) and early neonatal mortality decreased from 29 to 22/1000 (RR 0.74; 95% CI 0.53, 1.03). Mortality was not reduced further with resuscitation training. Conclusions: Using a pre–post design, World Health Organization Essential Newborn Care community birth attendant training resulted in a significant reduction in perinatal mortality. In low-resource settings, the newborn care training package appears to be an effective intervention to decrease perinatal mortality.     

The Egypt National Perinatal/Neonatal Mortality Study 2000.

OBJECTIVES: To estimate stillbirth, perinatal (PMR) and neonatal mortality rates (NMR) in Egypt and to assign main causes of death. STUDY DESIGN: Data were collected from a representative sample of women who gave birth from 17,521 households which were included in the Egypt Demographic and Health Survey (EDHS) 2000. Comparisons were made between three systems for classifying causes of death. RESULTS: The NMR was 25 per 1000 live births (17 early and eight late). Half the deaths occurred in the first two days of life. Neonatal causes of death were pre-maturity (39%), asphyxia (18%), infections (7%), congenital malformation (6%) and unclassified (29%). The PMR was 34 per 1000 births, mainly attributed to: asphyxia (44%) and prematurity (21%). The revised Wigglesworth classification agreed well with the physicians except the panel attributed more deaths to infections (20%). The WHO verbal autopsy algorithm left 48% of deaths unclassified. CONCLUSIONS: Infant mortality in Egypt is showing an epidemiological transition with a significant decrease in mortality, resulting in a disproportionate percentage of deaths in the first week of life. Infant mortality in Egypt declined 64% from 124 per 1000 between 1974 and 1978 to 44 per 1000 between 1995 and 1999, the decline being greatest among older infants; 55% of all infant deaths occurred during the neonatal period. The neonatal mortality rate in this study was estimated to be 25 per 1000 live births.     

Placental inflammation and perinatal outcome

OBJECTIVE: To examine the role of placental inflammation in adverse obstetrical outcome (AOO). METHODS: Analysis of perinatal data of 701 randomly selected mothers of singleton infants, Mombasa, Kenya. RESULTS: There were 661 (94.3%) live infants and 40 (5.7%) stillbirths. Out of the live born infants, 78 (12.4%) had a low birth weight (LBW < 2500g); 33 of them were preterm and 41 small for gestational age (SGA). The incidence of neonatal sepsis and post partum endometritis was 3.6 and 19.8%, respectively. The perinatal death rate was estimated to be 7.3% (51/701). The prevalence of acute placental inflammation was 19.6%. Acute placental inflammation was independently associated with preterm low birth weight (ARR=3.8, 95% CI=1.7-8.9, P<0.01), stillbirth (ARR=2.3, 95% CI=1.1-5.0, P=0.03) and perinatal death (ARR=2.8, 95% CI=1.4-5.4, P<0.01). Women with acute placental inflammation had a two-fold higher risk for AOO (32.6 versus 15.2%, respectively, ARR=2.5, 95% CI=1.3-4.8, P<0.01). Other risk factors for AOO were bad obstetrical history, low haemoglobin level and leucocytosis. CONCLUSIONS: The incidence of adverse obstetrical outcome defined as low birth weight, low Apgar score, perinatal mortality and post partum endometritis, was high in this population. Acute placental inflammation was associated with preterm birth, stillbirth and perinatal death. More research is needed to study the role of infection in adverse obstetrical outcome, and to design interventions to decrease infectious morbidity and mortality in pregnancy.     

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.     

The effects of maternal obesity on perinatal outcomes among those born small for gestational age*

Background: Maternal obesity has been associated with higher birth weight. Small for gestational age (SGA) neonates born to obese women may be associated with pathological growth with increased neonatal complications.

Methods: This was a retrospective cohort study of all non-anomalous singleton neonates born in Texas from 2006–2011. Analyses were limited to births between 34 and 42 weeks gestation with birth weight?≤10th percentile. Results were stratified by maternal pre-pregnancy BMI class. The risk for stillbirth, neonatal death, neonatal intensive care unit (NICU) admission and five?minute Apgar scores?<7 were estimated for each obesity class and compared to the normal weight group. Multivariable logistic regression analyses were performed to control for potential confounding variables.

Results: The rate of stillbirth was 1.4/1000 births for normal weight women, and 2.9/1000 among obese women (p?0.001, aOR: 1.83 [1.43, 2.34]). The rate of neonatal deaths among normal weight women was 4.3/1000 births, whereas among obese women it was 4.7/1000 (p?=?0.94, aOR: 1.10 [0.92, 1.30]). A dose-dependent relationship between maternal obesity and stillbirths was seen, but not for other neonatal outcomes.

Conclusion: Among SGA neonates, maternal pre-pregnancy obesity was associated with increased risks for stillbirth, NICU admission and low Apgar scores but not neonatal death.     

Subsequent birth outcomes after an unexplained stillbirth: preliminary population-based retrospective cohort study

The objective of this study was to determine whether women who have experienced an unexplained stillbirth have a higher risk of adverse perinatal outcomes in subsequent births. We compared 316 subsequent births to women with a previous unexplained stillbirth, with 3160 births to women with no previous history of stillbirth, matched by year of birth, in the period 1987-1997, from the South Australian perinatal database, using logistic regression analysis. There was no increase in the rate of stillbirth and no statistically significant increase in the rate of perinatal death (OR 1.62 [95%CI 0.63-4.20]) or neonatal death, although larger studies are needed to confirm this. However, after adjusting for age, parity, and hospital category of birth, women who had a previous stillbirth had increased incidences in subsequent births of abnormal glucose tolerance or gestational diabetes (a fourfold increase); induction of labour and elective Caesarean section; fetal distress and postpartum haemorrhage; and forceps and emergency Caesarean delivery and preterm birth, which were independent of induction of labour. Gestational age at birth and birthweight were also significantly reduced, suggesting a need for close monitoring of their future pregnancies.     

Once a cesarean always a cesarean? A computer-assisted decision analysis

Objective A previous decision analysis models for two strategic choices for trial of labor or repeated cesarean after prior cesarean concluded that the degree of wish for an additional future pregnancy appeared to be a major determinant for choice between the two strategic options. We had extended the analysis model to stillbirth and hypoxic-ischemic encephalopathy in addition to placental complications while updating most of the outcomes in the decision tree. Study design A model was formulated using a decision tree based on reported probabilities for various outcomes and estimated utilities. The question asked was should trial of labor or repeated cesarean be performed after a prior cesarean, with a varying desire for an additional pregnancy. The highest expected outcome determines the preference of our model. Results Our model favors repeated elective cesarean (0.9947) over trial of labor (0.9917) after a previous cesarean and is the preferred approach. This approach was preferable irrespective of the probability of additional pregnancy. Conclusion In contrary to previous models, when taking into account the occurrence of a live infant birth, birth of an infant with hypoxic-ischemic encephalopathy stillbirth, neonatal death, abnormal placental implantation, hysterectomy and maternal death the preferred approach for women with previous cesarean is an elective repeated cesarean rather than trial of vaginal delivery.