Reclassification of unexplained stillbirths using clinical practice guidelines

Background: Twenty-eight per cent of stillbirths in Australia remain unexplained. A clinical practice guideline (CPG) produced by the Perinatal Society of Australia and New Zealand (PSANZ) Perinatal Mortality Special Interest Group is in use to assist clinicians in the investigation and audit of perinatal deaths.
Aims: To describe in a tertiary hospital using the PSANZ stillbirth investigation guidelines: (i) the distribution and classification of stillbirths, and (ii) the compliance with suggested stillbirth core investigations.
Methods: Retrospective cohort of all stillbirths delivered between November 2005 and March 2008. Stillbirths were defined as no sign of life on delivery at ≥ 20 weeks gestation or 400 g birthweight if gestation is unknown. Data were collected via the hospital Perinatal Mortality Audit Committee (PMAC). Cause of death was classified by the PSANZ Perinatal Death Classification.
Results: There were 86 stillbirths (rate 7.2 per 1000 births). The percentage of unexplained stillbirths was 34% and 13% before and after CPG investigations, respectively. Unexplained stillbirths had the highest compliance with the recommended investigations. The initial cause of death documented on the death certificate was changed by the PMAC in 19 cases. The investigations most likely to prompt a change in the cause of death classification were autopsy and placental pathology.
Conclusions: The percentage of unexplained stillbirths is lower than the national average in a hospital using the Perinatal Mortality Audit Guidelines. However, overall compliance is low, suggesting a targeted approach to investigation is used by clinicians despite a policy that aims to be non-selective. Autopsy and placental examination are the most useful investigations in assisting formal classification of cause of death.     

The risk of unexplained antepartum stillbirth in second pregnancies following caesarean section in the first pregnancy

Objective  To determine if a previous caesarean section increases the risk of unexplained antepartum stillbirth in second pregnancies.
Study design  Retrospective cohort study.
Setting  Large Canadian perinatal database.
Population  158 502 second births.
Methods  Data were obtained from a large perinatal database, which supplied data on demographics, pregnancy complications, maternal medical conditions, previous caesarean section and pregnancy outcomes.
Main outcome measures  Total and unexplained stillbirth.
Results  The antepartum stillbirth rate was 3.0/1000 in the previous caesarean section group compared with 2.7/1000 in the previous vaginal delivery group ( P = 0.46). Multivariate logistic regression modelling, including terms for maternal age (polynomial), weight >91 kg, smoking during pregnancy, pre-pregnancy hypertension and diabetes, did not document an association between previous caesarean section and unexplained antepartum stillbirth (OR 1.27, 95% CI 0.92–1.77).
Conclusion  Caesarean section in the first birth does not increase the risk of unexplained antepartum stillbirth in second pregnancies.     

Monoamniotic twin pregnancies: antenatal management and perinatal results of 19 consecutive cases

Objective   To describe the obstetric management and perinatal outcome of antenatally diagnosed monoamniotic twin pregnancies (MATP) in a tertiary level maternity unit.
Setting   Port-Royal Maternity Hospital, Paris, France.
Population   MATP that progressed beyond 22 weeks seen from 1993 to 2001.
Methods   A retrospective chart review of all twin pregnancies. Diagnosis of MATP was made by ultrasonography and confirmed by placental pathology.
Main outcome measure   Perinatal mortality.
Results   Among the 1242 twins pregnancies delivered during the study period, 19 were monoamniotic. Four fetuses (10% of all births) had malformations. Perinatal mortality was high ( n = 12, 32%) because of fetal deaths (nine cases) and very preterm births (three neonatal deaths). No fetal deaths occurred after 29 weeks. Of the 15 women with at least one live fetus before labour, 6 gave birth by vaginal delivery (40%). No obstetric accidents occurred during vaginal deliveries.
Conclusion   Perinatal mortality of MATP is still very high, even with accurate, early antenatal diagnosis, intensified surveillance and delivery provided in a tertiary level hospital. The main causes of perinatal deaths are cord accidents in utero , congenital anomalies and very preterm births.     

Unexplained fetal death: Are women with a history of fetal loss at higher risk?

Aims: To identify factors, including the loss of a previous pregnancy before 20 weeks gestation, which are associated with increased risk of singleton antepartum unexplained fetal death (UFD) in Western Australia (WA) using information recorded in routine data collections.
Methods: All fetal deaths in WA from 1990 to 1999 that underwent thorough post-mortem investigations were classified using the Perinatal Society of Australia and New Zealand Perinatal Death Classification System. All UFDs were selected as cases and unmatched controls were randomly drawn from all live births in WA occurring during the study period. Demographic and clinical information on cases and controls was obtained from the WA Midwives' Notification System. Multivariable logistic regression was carried out to determine the independent effect of risk factors and calculate odds ratios.
Results: Almost one quarter (22%) of stillbirths were unexplained. Primigravid and primiparous women with a history of pregnancy loss before 20 weeks were at higher risk of UFD than multiparous women who had not experienced any loss. Women with a history of fetal death (after 20 weeks) had the highest risk of UFD.
Conclusion: The current practice of closely monitoring pregnant women with a history of fetal loss or death should continue as this study suggests they may have a higher risk of poor obstetric outcome. Larger studies are needed to confirm the association between previous pregnancy loss and UFD.     

Trends in the cause of late fetal death, 1982-2000

BACKGROUND: Progress in reducing late fetal deaths has slowed in recent years, despite changes in intrapartum and antepartum care. OBJECTIVES: To describe recent trends in cause-specific fetal death rates. DESIGN: Retrospective cohort study. SETTING: North of England. POPULATION/SAMPLE: 3,386 late fetal deaths (> or = 28 weeks of gestation and at least 500 g), occuring between 1982 and 2000. METHODS: Data on deaths were obtained from the Northern Perinatal Mortality Survey. Data on live births were obtained from national birth registration statistics. Rate ratios (RR) and 95% confidence intervals (CI) for fetal deaths in 1991-2000 compared with 1982-1990 were calculated. MAIN OUTCOME MEASURES: Cause-specific late fetal death rates per 10,000 total births. RESULTS: Mortality in singletons declined from 51.5 per 10,000 births in 1982-1990 to 42.0 in 1991-2000 (RR 0.82, 95% CI 0.76-0.87). There was a greater decline in multiples, from 197.9 to 128.0 per 10,000 (RR 0.65, 95% CI 0.51-0.83). In singletons, the largest reductions occurred in intrapartum-related deaths, and deaths due to congenital anomalies, antepartum haemorrhage and pre-eclampsia. There was little change in the rate of unexplained antepartum death occurring at term (RR 0.97, 95% CI 0.84-1.11) or preterm (RR 0.94, 95% CI 0.82-1.07), these accounting for about half of all late fetal deaths. Unexplained antepartum deaths declined in multiple births and in singletons of birthweight < 1500 g. CONCLUSIONS: While late fetal mortality due to many specific causes has declined, unexplained antepartum death rates have remained largely unchanged. Improved identification of deaths due to growth restriction and infection, which may otherwise be classified as unexplained, is important. Further investigation of the underlying aetiologies of genuinely unexplained deaths is needed.     

The impact of multiple pregnancies and malformations on perinatal mortality

AIM: To evaluate the impact of the rate of multiple pregnancies and congenital malformations on perinatal mortality. METHODS: The study is based on data from the perinatal audit in Vejle County Denmark. Fetal deaths with gestational age > or = 22 weeks and deaths in livebirths within the first 28 days after birth were included in the calculated perinatal mortality. Total number of births was 30,181 and 252 pregnancies and 268 fetuses/infants were evaluated. The study period was 1995-2000. There was no routine ultrasound screening for congenital malformations in the county, though midtrimester ultrasound was used to assess gestational age. RESULTS: Perinatal mortality was 8.9 per 1000 births with no significant change over time. Rate of multiple pregnancies was 1.94% ranging from 1.81% during the first 3 years to 2.06% for the last 3 years (not significant). Fetuses and infants from multiple pregnancies contributed 18% of all deaths. Perinatal mortality for single births was 7.6 per 1000 births and for multiple births 42.2/1000 (P<0.0001). The distribution of gestational age for single and multiple births was highly significant (P<0.0001) with 67% of multiple pregnancies with GA < 28 weeks compared to 26% of single pregnancies. Nineteen percent of all deaths were caused by congenital malformations and the majority of these were potentially detectable by ultrasound investigation. CONCLUSIONS: The increasing rate of multiple pregnancies makes it difficult to see improvements in perinatal mortality. Calculated from the perinatal mortality in single and multiple pregnancies in Vejle County assisted conceptions contribute with an an excess of 45 perinatal deaths per year in Denmark. The difference between countries in rate of multiple pregnancies and in prenatal ultrasound screening recommendations for malformations makes it difficult to compare perinatal mortality.     

Perinatal mortality in first- and second-born twins in the United States

OBJECTIVE: To evaluate the prevailing mortality paradox that second-born twins are at higher risk of perinatal mortality than first-born twins. METHODS: We used the 1995-1997 United States "matched multiple birth" data files assembled by the National Center for Health Statistics, for analysis of risk of perinatal mortality in first- and second-born twins (293788 fetuses). Perinatal mortality was defined to include stillbirths after 20 weeks of gestation and neonatal deaths (deaths within the first 28 days). Gestational age-specific risk of perinatal mortality (per 1000 total births), stillbirth (per 1000 total births), and neonatal mortality (per 1000 livebirths) by order of twin birth were based on the fetuses-at-risk approach. Associations between order of birth and mortality indices were evaluated by fitting multivariable logistic regression models based on the method of generalized estimating equations. These models were adjusted for several potential confounding factors. RESULTS: Perinatal mortality was 37% higher in second-born (26.1 per 1000 total births) than in first-born (20.3 per 1000 total births) twins (adjusted relative risk [RR] 1.37; 95% confidence interval [CI] 1.32, 1.42). The increased risk of perinatal mortality in second-born twins was chiefly driven by a 2.46-fold (95% CI 2.29, 2.63) increase in the number of stillbirths. However, the risk of neonatal mortality was very similar between first- and second-born twins (RR 0.99, 95% CI 0.95, 1.04). CONCLUSIONS: The increased risk of perinatal death in second-born twins is driven chiefly by increased rates of stillborn second twins. Thus, the increased mortality in second-born over first-born twins probably is an artifact of mortality comparisons.     

Clinical causes and classification of perinatal mortality in Lagos

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

Perinatal mortality and morbidity rates among singleton,twin, and triplet gestations

Objective: To determine rates of perinatal mortality and morbidity from 24 to 43 weeks gestation among singletons, twins, and triplets.Methods: Successfully linked data from 1992 Californian maternal and infant discharge records as well as birth and death certificates from acute care civilian hospitals were examined for perinatal mortality and morbidity. Perinatal mortality was defined as the sum of all stillbirths and neonatal deaths. Deliveries from 24 to 43 weeks gestation among singleton, twin, and triplet pregnancies were collected as separate data sets. Perinatal mortality was identified using birth certificate death indicators excluding deaths caused by congenital anomalies. Neonatal deaths were identified from death indicators found in the death certificates. For the purpose of this study, perinatal morbidities were identified by ICD-9 codes and limited to respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), and necrotizing enterocolitis (NEC). Perinatal mortality and morbidity rates were expressed as a percent of live births stratified by gestational age. Perinatal mortality data were expressed in log scale and perinatal morbidity rates were statistically compared.Results: There were 571,390 total births in California of which 527,677 (92%) were singleton, 12,535 (2%) were twin, and 367 (0.06%) were triplet gestations. Across gestation, the rate of RDS between triplets and twins was comparable (6.6% vs 6.8%). However, the rates of IVH and NEC were significantly greater in triplets than in twins (20% vs 8%, P < .0001, and 25% vs 9%, P < .0001, respectively). The perinatal mortality rates are shown below.

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Conclusions: Perinatal mortality rates were comparable among singleton, twin, and triplet gestations delivered between 24 and 30 weeks gestation. Unlike singletons and twins, the triplet perinatal mortality rate did not fall between 31 and 36 weeks gestation and remained at 2.6%. Twin perinatal mortality rate was equivalent to singletons until 36 weeks gestation. IVH and NEC were significantly greater among triplets regardless of gestational age. These data suggest that antepartum fetal surveillance of triplet pregnancies should start as early as 30 weeks gestation while testing for twin pregnancies can begin at 36 weeks gestation.     

11. Perinatal mortality

Summary. The perinatal mortality rate in all singleton births was 103 per 1000; 67% of all perinatal deaths were stillbirths and in 77% of stillbirths, intrauterine death had already occurred before admission to hospital. Nine per cent of live births but 40% of stillbirths and 50% of neonatal deaths were of low birthweight (≤2.5 kg). The principal obstetric causes of perinatal deaths were obstructed labour and its consequences, anaemia, antepartum haemorrhage, eclampsia and low fetal birthweight. Nearly half of all perinatal deaths were associated with complicated deliveries of which vaginal breech delivery was by far the most hazardous. Both the proportion of babies with low birthweight and the perinatal mortality rates rose dramatically and progressively with haematocrit <0.30. A raised perinatal mortality rate was also associated with raised haematocrit >0.40. Of the biosocial factors influencing perinatal health, lack of antenatal care, residence outside Zaria, early teenage pregnancy and high parity exerted the most deleterious effect and literacy and antenatal care the most favourable effect on pregnancy outcome.     

Birth Centers in Australia: A National Population‐Based Study of Perinatal Mortality Associated with Giving Birth in a Birth Center

ABSTRACT: Background: Perinatal mortality is a rare outcome among babies born at term in developed countries after normal uncomplicated pregnancies; consequently, the numbers involved in large databases of routinely collected statistics provide a meaningful evaluation of these uncommon events. The National Perinatal Data Collection records the place of birth and information on the outcomes of pregnancy and childbirth for all women who give birth each year in Australia. Our objective was to describe the perinatal mortality associated with giving birth in “alongside hospital” birth centers in Australia during 1999 to 2002 using nationally collected data. Methods: This population‐based study included all 1,001,249 women who gave birth in Australia during 1999 to 2002. Of these women, 21,800 (2.18%) gave birth in a birth center. Selected perinatal outcomes (including stillbirths and neonatal deaths) were described for the 4‐year study period separately for first‐time mothers and for women having a second or subsequent birth. A further comparison was made between deaths of low‐risk term babies born in hospitals compared with deaths of term babies born in birth centers. Results: The total perinatal death rate attributed to birth centers was significantly lower than that attributed to hospitals (1.51/1,000 vs 10.03/1,000). The perinatal mortality rate among term births to primiparas in birth centers compared with term births among low‐risk primiparas in hospitals was 1.4 versus 1.9 per 1,000; the perinatal mortality rate among term births to multiparas in birth centers compared with term births among low‐risk multiparas in hospitals was 0.6 versus 1.6 per 1,000. Conclusions: This study using Australian national data showed that the overall rate of perinatal mortality was lower in alongside hospital birth centers than in hospitals irrespective of the mother’s parity. (BIRTH 34:3 September 2007)     

Trends in prevalence and outcomes of pregnancy in women with pre-existing type I and type II diabetes

Objective  To describe recent trends in prevalence, outcomes and indicators of care for women with pre-existing type I or type II diabetes.
Design  Regional population-based survey.
Setting  All maternity units in the North of England.
Population  A total of 1258 pregnancies in women with pre-existing diabetes delivered between 1996 and 2004.
Methods  Data from the Northern Diabetic Pregnancy Survey. Outcome of pregnancy cross-validated with the Northern Congenital Abnormality Survey and the Northern Perinatal Mortality Survey.
Main outcome measures  Perinatal mortality, congenital anomaly and total adverse perinatal outcome (perinatal mortality and live births with congenital anomaly).
Results  The prevalence of pregestational diabetes increased from 3.1 per 1000 births in 1996–98 to 4.7 per 1000 in 2002–04 (test for linear trend, P < 0.0001), driven mainly by a sharp increase in type II diabetes. Perinatal mortality declined from 48 per 1000 births in 1996–98 to 23 per 1000 in 2002–04 ( P = 0.064). There was a significant reduction in total adverse perinatal outcome rate ( P = 0.0194) from 142 per 1000 in 1996–98 to 86 per 1000 in 2002–04. There were substantial improvements in indicators of care before and during pregnancy and in glycaemic control throughout pregnancy, but indicators of preconceptual care, such as use of folic acid, remained disappointing.
Conclusion  We observed improvements in pregnancy care and outcomes for women with diabetes in a region with an established audit and feedback cycle. There remains considerable scope for further improvement, particularly in periconceptual glycaemic control. The rising prevalence of type II diabetes presents a challenge to further improvement.     

Life-table analysis of the risk of perinatal death at term and post term in singleton pregnancies

OBJECTIVE: This study was undertaken to estimate the cumulative risk of perinatal death associated with delivery at each gestational week both at term and post term. STUDY DESIGN: The numbers of antepartum stillbirths, intrapartum stillbirths, neonatal deaths, and surviving neonates delivered at between 37 and 43 weeks' gestation in Scotland, 1985-1996, were obtained from national databases (n = 700,878) after exclusion of multiple pregnancies and deaths caused by congenital abnormality. The numbers of deaths at each gestational week were related to appropriate denominators: antepartum stillbirths were related to ongoing pregnancies, intrapartum stillbirths were related to all births (excluding antepartum stillbirths), and neonatal deaths were related to live births. The cumulative probability of perinatal death associated with delivery at each gestational week was estimated by means of life-table analysis. RESULTS: The gestational week of delivery associated with the lowest cumulative risk of perinatal death was 38 weeks' gestation, whereas the perinatal mortality rate was lowest at 41 weeks' gestation. The risk of death increased more sharply among primigravid women after 38 weeks' gestation because of a greater risk of antepartum stillbirth. The relationships between risk of death and gestational age were similar for the periods 1985-1990 and 1991-1996. CONCLUSION: Delivery at 38 weeks' gestation was associated with the lowest risk of perinatal death.     

Implementing a facility-based maternal and perinatal health care surveillance system in Afghanistan

Afghanistan has one of the highest maternal and perinatal mortality rates in the world. Lack of a health information system presented obstacles to efforts to improve the quality of care and reduce mortality. To rapidly overcome this deficit in a large women's hospital, staff implemented a facility-based maternal and perinatal surveillance system known as "BABIES," which is specially designed for intervention and evaluation in low-resource settings. During a 12-month period, 15,509 deliveries resulted in 28 maternal deaths and a perinatal mortality rate of 56 per 1000 births. When stratified by birth weight and perinatal period of death, fetuses weighing at least 2500 g who died during the antepartum period contributed the most cases of perinatal death. This finding suggests that the greatest reduction in perinatal mortality would be realized by increasing access to high-quality antepartum care. Among fetuses weighing at least 2500 g, 93 deaths occurred during the intrapartum period. These deaths will continue to be monitored to ensure that the chosen interventions are improving intrapartum care for mothers and newborns. Because of its simplicity, flexibility, and ability to identify interventions, BABIES is a valuable tool that enables clinicians and program managers to prioritize resources.     

Perinatally related wastage–a proposed classification of primary obstetric factors

Summary. Adapting Sir Dugald Bairďs concept of primary obstetric causes of perinatal mortality, a revised clinico-pathological classification has been evolved to take account of new knowledge and developments, and to direct attention to potentially avoidable deaths and to where intensified efforts and investigation are needed. Categories highlighting the importance of intrauterine growth retardation, unexplained intrauterine death and spontaneous premature labour have been introduced, intrapartum hypoxia is separated from birth trauma, and infection again has its own category. Regular perinatal audit at one obstetric hospital, since 1979, has shown that the new system provides a workable and useful means for classifying not only perinatal deaths, but also late abortions, late neonatal deaths and perinatally related infant deaths. The rate of total perinatally related wastage, defined in this way, was almost twice that for perinatal mortality (22-8 compared with 11·9 per 1000 births). The former is advocated as a more realistic index for the audit of perinatal care. The revised and extended system is put forward as a contribution to the current debate on classifying and reporting such wastage, in the hope that it may be tested as a model for regional as well as hospital surveys.     

Perinatally related wastage—a proposed classification of primary obstetric factors

Summary. Adapting Sir Dugald Bairďs concept of primary obstetric causes of perinatal mortality, a revised clinico-pathological classification has been evolved to take account of new knowledge and developments, and to direct attention to potentially avoidable deaths and to where intensified efforts and investigation are needed. Categories highlighting the importance of intrauterine growth retardation, unexplained intrauterine death and spontaneous premature labour have been introduced, intrapartum hypoxia is separated from birth trauma, and infection again has its own category. Regular perinatal audit at one obstetric hospital, since 1979, has shown that the new system provides a workable and useful means for classifying not only perinatal deaths, but also late abortions, late neonatal deaths and perinatally related infant deaths. The rate of total perinatally related wastage, defined in this way, was almost twice that for perinatal mortality (22–8 compared with 11.9 per 1000 births). The former is advocated as a more realistic index for the audit of perinatal care. The revised and extended system is put forward as a contribution to the current debate on classifying and reporting such wastage, in the hope that it may be tested as a model for regional as well as hospital surveys.     

The changing pattern of fetal death, 1961-1988.

The aim of this study was to assess any changes in cause-specific fetal death rates in the nonreferred population of a tertiary care unit. The fetal death rate (per 1000 births) among 88,651 births diminished from 11.5 in the 1960s to 5.1 in the 1980s. Fetal death due to intrapartum asphyxia and Rh isoimmunization has almost disappeared. Toxemia and diabetes continue to make similar and small contributions to fetal death rates. There has been a significant decline in unexplained antepartum fetal deaths and in those caused by fetal growth retardation, but no significant change in the death rate due to intrauterine infection or abruptio placentae. During the 1960s, the risk of fetal death was increased in women with hypertension, diabetes, or a history of stillbirth; during the 1980s, only women with a history of insulin-dependent diabetes were at risk. Improved application of current knowledge may help decrease the fetal death rate caused by fetal growth retardation. Reduction in deaths due to abruptio placentae, intrauterine infections, or lethal malformations, as well as unexplained antepartum deaths, appears to depend on better understanding of the etiology of these disorders.     

Perinatally related wastage--a proposed classification of primary obstetric factors

Adapting Sir Dugald Baird's concept of primary obstetric causes of perinatal mortality, a revised clinico-pathological classification has been evolved to take account of new knowledge and developments, and to direct attention to potentially avoidable deaths and to where intensified efforts and investigation are needed. Categories highlighting the importance of intrauterine growth retardation, unexplained intrauterine death and spontaneous premature labour have been introduced, intrapartum hypoxia is separated from birth trauma, and infection again has its own category. Regular perinatal audit at one obstetric hospital, since 1979, has shown that the new system provides a workable and useful means for classifying not only perinatal deaths, but also late abortions, late neonatal deaths and perinatally related infant deaths. The rate of total perinatally related wastage, defined in this way, was almost twice that for perinatal mortality (22.8 compared with 11.9 per 1000 births). The former is advocated as a more realistic index for the audit of perinatal care. The revised and extended system is put forward as a contribution to the current debate on classifying and reporting such wastage, in the hope that it may be tested as a model for regional as well as hospital surveys.     

A review of perinatal mortality in an urban situation in a developing country

Perinatal deaths occurring within the City of Harare, Zimbabwe, during 1983 were studied. Data were collected from all known deliveries within the city. This included exact numbers from three central maternity hospitals, and from referring midwife-run maternity clinics. An estimate was made of the number of births and perinatal deaths occurring within the city, but outside these official maternity facilities. All perinatal deaths were reviewed. The birthweight, the cause of death, and the antenatal care registration status of the mother were established. There were 2103 perinatal deaths from an estimated 53,665 total births. Deliveries include 50,138 (93.4%) in hospitals or clinics, 972 (1.8%) before arrival to the maternity service, and an estimated 2555 (4.8%) outside the city maternity services. One thousand seven hundred and fourteen (81.5%) perinatal deaths occurred in hospital or clinic delivered babies, and 134 (6.4%) from babies delivered before arrival at medical services. An estimated 255 (12.1%) of deaths occurred elsewhere. A total of 6380 (12%) patients did not register for antenatal care. There were 909 (43.2%) perinatal deaths in this unregistered group of patients. The overall perinatal mortality rate (PNMR) for infants weighing 500 g or more was 39.2/1000. For registered patients the PNMR was 25.3/1000 and for unregistered patients, 142.5/1000. For infants weighing 1000 grams or more the PNMR was 31.6/1000. The causes of death in the 2103 perinatal deaths were established and classified by clinical cause and by a simple pathological grouping with breakdown by birthweight.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.