Perinatal mortality in an institution where nurse aides conduct deliveries, Nkayi District, Zimbabwe

OBJECTIVE

To evaluate the perinatal mortality and describe the effects of nurse aide conducted deliveries on it at Mbuma hospital, Nkayi District, an institution where nurse aides conduct deliveries.

DESIGN

Retrospective descriptive study based on review of maternal records from January 1992 to December 1994.

SETTING

Mission hospital situated in a rural area.

MAIN OUTCOME MEASURES

The training which the health worker who conducted the delivery had and the pregnancy outcomes.

RESULTS

1459 deliveries were conducted and of these 824 (57pc) were conducted by nurse aides. The perinatal mortality of the nurse aide conducted deliveries was five per 1000 births and that of the trained staff was 57 per 1000 births.

CONCLUSIONS

Nurse aides conducted more than half the total deliveries at the hospital. The hospital referral system, where normal deliveries are conducted by nurse aides while primigravidas and complicated cases are conducted by trained staff is working well as supported by the low perinatal mortality of the nurse aide conducted deliveries.

Community based estimation of perinatal mortality through record linkage

OBJECTIVE

To estimate perinatal mortality through record linkage of Health Workers (HW) and Anganwadi Workers (AWW) in rural Haryana.

DESIGN

Retrospective analysis of records (1991-92) of HW and AWW. Enquiry and home visits were made for tracing the fate of pregnancy in cases with incomplete records.

SETTING

In 1993-95 in 45 villages selected purposively in Raipur Rani block, Ambala.

MAIN OUTCOME MEASURE

Enlisting of perinatal deaths as the main outcome measure through scrutiny of records of HW and AWW.

RESULTS

Perinatal mortality rate (PMR) was 42.25 and 45.78 per thousand births as per the record of HW and AWW, respectively for the 23 villages for whom records of both were available. Support by enquiry or home visit yielded a PMR of 59.42 for combined HW and AWW sources and 51.66 per 1000 births for AWW source alone. Concordance between AWW and HW records for fate of pregnancy was moderate (K = 0.46; 95% CI 0.35-0.57).

CONCLUSIONS

There is a lack of a system of record linkage between and within the records of HW and AWW at primary health care level. AWW data was more accurate and up-to-date as compared to HW. Reasonably accurate estimates of perinatal mortality rate can be made through record linkage.

Perinatal morbidity and mortality in offspring of diabetic mothers in Qatif, Saudi Arabia

Diabetic mothers and their offspring were prospectively studied. Perinatal and neonatal morbidity and mortality data were analysed. Out of 11,677 deliveries in the hospital, 133 (1.14%) were delivered by diabetic mothers. They were made up of six (4.5%) stillbirths and 127 (95.5%) live births. Seventy-seven (57.9%), 55 (41.3%) and 1 (0.8%) were large, appropriate and small for gestational age, respectively. Hypoglycemia occurred in 49 (38.6%) of the 127 infants. Other associated problems were bacterial infections, congenital anomalies, birth trauma, preterm delivery, respiratory distress, polycythaemia and anaemia. Only 52 (39.1%) of the mothers received appropriate treatment for their diabetes during pregnancy. Poor maternal diabetic control resulted in high perinatal morbidity and mortality in the offspring. In order to improve the outcome in offspring of diabetic mothers in Qatif and probably Saudi Arabia as a whole, health education and improved care of the diabetic mothers during pregnancy urgently needed. This may be true of other developing countries where data on diabetes in pregnancy are scarce.

Perinatal mortality in urban slums in Lucknow

OBJECTIVES

To determine the perinatal mortality rate (PNMR) in the urban slums of Lucknow

DESIGN

Cross-sectional survey.

SETTING

Twenty five Anganwadi centres of urban Lucknow, with a population of 25,901.

METHODS

Data was collected on birth and early neonatal deaths, gestational age of the neonate (determined at birth) and maternal variables like socio-economic status, maternal age, parity, and bad obstetrical history from January 1992 to March 1993.

RESULTS

There were 966 births with a still-birth rate of 37.2 and PNMR of 59.0 per 1000. The relative risk of perinatal mortality with lower socio-economic status was 1.87, bad obstetrical history 2.18, and gestational age < 37 weeks 1.95.

CONCLUSIONS

Further reduction in PNMR may be possible with focussed medical services to women of low socio-economic status having bad obstetrical history and those delivering before term.

Perinatal outcome in pregnancy induced hypertension

Perinatal outcome and the factors affecting it were studied in 140 pregnant women with hypertension. Perinatal mortality rate (PNM) was 140/1000 and the stillbirth rate was 8.7%. In severe hypertension PNM was 52.3% and all perinatal deaths were 8.7%, when the serum uric acid level were more than 4.5 mg%.

A ten-year review of uterine rupture in modern obstetric practice

The aim of this paper is to determine the antecedent factors, clinical presentation, complications and management of uterine rupture in the context of modern obstetric practice in Singapore. We conducted a retrospective study of 26 proven cases of uterine rupture in Kandang Kerbau Hospital, Singapore between January 1983 to December 1992. These cases were analysed with regards to their past history, clinical presentation, complications, management and outcome. The incidence of uterine rupture was 1 in 6331 deliveries. The ratio of cases with scarred uteri against those with unscarred uteri was 3:1. The commonest antecedent factor was previous lower segment caesarean section for the scarred group and cephalo-pelvic disproportion in the unscarred group. Overall, 46.2% of the patients had augmentation with oxytocin. The major clinical presentations were abnormal cardiotocogram (25%) and blood-stained amniotic fluid (20%) in the scarred group, and postpartum haemorrhage (50%) and shock (33%) in the unscarred group. Repair of the uterus with or without tubal ligation was performed in 95% of the patients with scarred uteri, whereas 67% of the patients with unscarred uteri underwent total abdominal hysterectomy with or without salpingo-oophorectomy. There was 1 (3.8%) maternal death. Maternal morbidity included bladder injuries, broad ligament haematoma, disseminated intravascular coagulation and gastrointestinal bleeding. The overall incidence of fetal loss was 7.4%. When compared to a previous study on uterine rupture in the same hospital, there was an improvement in obstetric performance.

Differential fertility of mothers of twins and mothers of singletons: study in Limon, Costa Rica

The reproductive performance of mothers of twins is of interest from an evolutionary perspective. Because mothers of twins have the potential of leaving a greater number of offspring, they could be favored by natural selection. At the same time, twin pregnancies are known to be associated with higher pre- and postnatal mortality. Thus mothers of twins at least have potentially higher fertility, a potential that may be hampered by greater mortality of twins. Here, I examine the completed fertility of 149 females, 50 years of age and older, from Limon, Costa Rica. In particular, the number of surviving children of mothers of twins and mothers of singletons at the time of the interview is compared. In this sample mothers of twins have a higher fertility at the end of their reproductive career. Their selection coefficient indicates that natural selection favors them through differential fertility.

Symphysiotomy or caesarean section after failed trial of assisted delivery

The perinatal and maternal outcomes of 65 symphysiotomies and 108 caesarean sections carried out after failed trial of assisted delivery at the Port Moresby General Hospital between 1988 and 1994 were retrospectively analyzed. There were no significant differences in perinatal outcomes between the treatment groups. There were no maternal deaths in either group. Mothers who had symphysiotomy had a longer postoperative stay in hospital but fewer complications requiring further surgery. There are many advantages of symphysiotomy, particularly in developing countries, following a failed trial of assisted delivery, provided the indications for it are strictly met. Obstetricians experienced in the technique are able to apply it at the optimal time, with long-term benefit to their patients, who thereby avoid the risks of pregnancy subsequent to caesarean section.

Effect of changing the stillbirth definition on evaluation of perinatal mortality rates

The perinatal mortality rate is widely used as a summary statistic for evaluating the effectiveness of perinatal care. Since October, 1992, it has been a legal requirement in England and Wales to register fetal deaths at 24-27 completed weeks of gestation as stillbirths (in addition to those after 28 weeks), thereby altering the definition of perinatal death. In a cohort analysis of all babies born to women resident in Wales during 1993, we assessed whether the revised definition of perinatal mortality rate more appropriately measures effectiveness of care. There were 36,793 births and 313 perinatal deaths (221 stillbirths, 92 early neonatal deaths). At 24-27 weeks' gestation there were 59 (39%) survivors and 93 deaths (52 stillbirths, 36 neonatal deaths [28 early, eight late], and 5 postneonatal deaths). 119 babies had a birthweight below 500 g; one survived and 24 were perinatal deaths. Of the 36 late neonatal deaths all were attributed to perinatally related events. Increased survival of infants at 24-27 weeks' gestation emphasises the importance of including all these infants in the perinatal mortality rate, but it would be a more useful measure of the effectiveness of perinatal care if it excluded babies below 500 g, and included late neonatal deaths.

Breech delivery and foetal outcome: a review of 291 cases

In a three year period (September 1989 to August 1992), among 7,170 consecutive deliveries at Yekatit 12 Hospital, Addis Abeba, Ethiopia, there were 291 singleton breech deliveries with a 4% incidence rate at a gestational age of 28 weeks and above. In 28% and 57% of the infants, weight was below 2,500 grams and Apgar score was less than 7 in the first minute, respectively. The gross perinatal mortality rate for breech delivery in the first 24 hours was 330 per 1,000 deliveries, which was significantly higher than for the total number of deliveries (70 per 1,000; p < 0.001). However, the perinatal mortality rate was 1,000 per 1,000 deliveries for foetuses of less than 1,500 grams, 635 for foetuses between 1,500-2,500 grams, and 156 for foetuses of greater than 2,500 gm. In general, foetuses with low birth weight showed a high mortality rate (p < 0.001). There was also a two-fold increase in perinatal death in patients without antenatal care (p < 0.001). In order to reduce this unacceptably high perinatal mortality, emphasis must be given to appropriate training of physicians and midwives in the management of breech deliveries along with provisions of efficient prenatal care to improve birth weight. In addition, as most of the neonatal problems are preventable, measures need to be taken to establish neonatal units equipped with basic resuscitation materials and manpower.

Influences of selected socioeconomic and demographic variables on fertility in Bangladesh

"The data used in this study are from the 1989 Bangladesh Fertility Survey (1989 BFS), which was conducted...by the National Institute of Population Research and Training (NIPORT)....A two-stage probability sample design was used for the survey.... It has been found that female age at marriage has a significant direct negative influence on fertility. Thus, raising the age at marriage by implementing a minimum-age marriage law is likely to lower fertility on a national scale. Duration of breast-feeding is also found to have a significant direct negative effect on fertility....Fetal loss appears to have a significant direct positive effect on fertility...which means that mothers who have experienced fetal loss are found to have higher fertility.... Maternal mortality is also high in Bangladesh. Therefore, it is essential to provide primary health care, particularly maternal and child health care, for surviving children."

[Perinatal mortality]

Eighty six cases of perinatal mortality at Hospital de Ginecoobstetricia, Garza García, N.L. Subsecretaría Estatal, from january, 1992 to December, 1993, were reviewed. Perinatal mortality was 12.0 by one thousand births, less than in other reports. The highest incidence was in young patients, 20 to 29 years old, with 47.7% and with parity of 1 to 3, 80.2%; highest frequency in term pregnancies, 37 to 42 weeks, 39.6%; 35% of the products with weight over 2,500 g; and 65% with lesser weight; fetal death occurred most frequently during pre-partum, 55.8%, and less during intra-partum, 19.8%. Most frequent causes of peri-natal death were placental failure, 27.9% and fetal immaturity, with 24.4%. It is concluded that an adequate pre-natal control and delivery surveillance produce a diminution in fetal mortality.

A comprehensive index for longitudinal monitoring of child health status

The aim of this study was to develop a single comprehensive index of child mortality for longitudinal assessment of health status of children. The need for such a comprehensive index arose from conflicting trends in different child mortality indicators. The data for the study was taken from the Sample Registration System (SRS) reports of the Registrar General of India. SRS is known to provide reliable estimates of births and deaths at the State and the National level. The study included five child mortality indicators, namely, under five mortality rate (U5MR), infant mortality rate, neonatal mortality rate, perinatal mortality rate and still birth rate. These were available for fifteen states of India over the years 1972-1988. To develop this index we modified an earlier method based on factor analysis. Factor analysis of data on various indicators of child mortality revealed two factors which together explained 78% to 93% of the total variation in different years. The first factor was identified as representing mortality after birth and the second as before and during birth. The comprehensive index was obtained as a linear combination of these two factors. The resultant index thus fairly represented all five mortality indicators and provided a comprehensive and reasonably correct picture of child mortality. The lower the magnitude of this index, the better was the child health status. Trends in the index showed that the highest decline in the magnitude was in the state of Kerala followed by Punjab, Andhra Pradesh, Gujarat and Maharashtra in that order. This indicates steady improvement of the child health status over years in these states. In the State of Jammu and Kashmir, the index remained more or less constant over the years though the magnitude was low in the cross-sectional comparison with other states. Thus the comprehensive index developed by using factor analysis of the various mortality indicators can be used for the longitudinal monitoring of child health status in the states of India.

Vaginal misoprostol as an alternative to oxytocin for induction of labor in women with late fetal death

BACKGROUND

Induction of labor in women with late fetal death is often difficult in settings with scarce resources. The purpose of this study was to assess the value of vaginal misoprostol for induction of labor in women with such fetal death.

METHODS

In Maputo 156 women with late fetal death were allotted in a non-randomised way to either vaginal misoprostol or intravenous infusion of oxytocin. Treatment outcomes were compared as to cost-effectiveness and safety. In the misoprostol group none received more than 800 micrograms. Oxytocin infusion followed an established routine. Statistical analyses were performed by EPI Info software.

RESULTS

In cases with Bishop's score < 6 the induction-to-delivery interval averaged 14.8 hours in the misoprostol group and 31.0 hours in the oxytocin group (p = 0.001). The corresponding values for women with Bishop's score > or = 6 were 6.6 and 8.7 hours, respectively (p = 0.4). Women with intact membranes had an induction-to-delivery interval of 13.8 hours in the misoprostol group and 26.9 hours in the oxytocin group (p = 0.002). The corresponding values in women with ruptured membranes were 7.8 and 10.5 hours, respectively (p = 0.6). Successful induction was achieved in 81% of misoprostol-treated women at a dose of 100 micrograms or less.

CONCLUSIONS

Vaginal misoprostol is a safe, low-cost drug particularly suitable in women of high average parity having late, fetal death.

Towards a safer motherhood

One hundred cases each, in induced and spontaneous labour, were analysed to compare which group could achieve safer motherhood. It was observed that induced group with controlled labour has many maternal and foetal advantages like undisturbed domestic arrangements, avoidance of fatigue of patients and her relations, short duration of labour and minimal exposure to stress of labour, lower incidence of caesarean section and minimised perinatal morbidity and mortality.

Perinatal mortality in home births in rural Tanzania

OBJECTIVE

To compare perinatal mortality, stratified for risk level, in home births attended by a relative or traditional birth attendant without formal training with births attended by trained personnel in a dispensary or hospital.

STUDY DESIGN

A prospective community based study in five villages in Northwestern Tanzania during 1990, involving 222 women delivering at home and 199 in a dispensary or hospital.

RESULTS

Twenty-two of the 29 (76%) perinatal deaths occurred in home births. Perinatal mortality, stratified for risk level, was three times higher in home births than it was in births in dispensaries or in hospital (Mantel-Haenszel odds ratio, 3.29; 95% CI, 1.28-9.22).

CONCLUSIONS

This study re-emphasises that all births should be attended by adequately trained personnel. More effective strategies are needed to convince women with high risk pregnancies to deliver in hospital. Emergency referral services are required to deal with unexpected complications arising in low risk births at home.

Maternal weight, height and risk of poor pregnancy outcome in Ahmedabad, India

This paper explores the relationships between maternal weight, height and poor pregnancy outcome using a data set from a case-control study of low birth weight (LBW) and perinatal mortality in Ahmedabad, India. Maternal height and weights were compared between mothers of 611 perinatal deaths, 644 preterm-LBW, and 1465 normal birth weight controls as well as 617 small-for-gestational age (SGA) and 1851 appropriate-for-gestational-age (AGA) births. Weight and height were much lower in this population compared to western standards. Low weight and height were associated with increased risk of perinatal death, prematurity and SGA. After adjusting for confounders, maternal weight remained significantly associated with poor pregnancy outcomes, whereas height was only weakly associated. Attributable risk estimates show that low weight is a much more important contributor to poor outcome than low height. Improvement in maternal nutritional status could lead to substantial improvement in birth outcome in this population.

Risk factor analysis of peri-neonatal mortality in rural Guatemala

Peri-neonatal mortality is a serious health problem in Guatemala, especially in rural areas where most deliveries occur at home and are overseen by traditional birth attendants (TBAs) who function in the role of midwives. The three aims of the work reported here were to identify important predictors of peri-neonatal mortality within a rural area of Guatemala; to assess the effects of traditional and modern health care providers on such mortality; and to find ways of identifying high-risk women who might benefit from transfer to a hospital or clinic. For these purposes a case-control study was conducted of 120 women in the rural department of Quetzaltenango who had lost their babies from the 20th week of pregnancy through the 28th day of life. These women and 120 controls were interviewed in their homes by trained physicians, using questionnaires in Spanish or the appropriate Indian dialect, and the results were analyzed through a series of statistical tests. It was found that the complications of pregnancy and delivery with the greatest statistical significance were prematurity, malpresentation, and prolonged labor. Population-based attributable risks of these complications demonstrated that they accounted for significant proportions of the observed peri-neonatal mortality. While these conditions cannot be eliminated, within the rural Guatemalan context it appears that early referral of women with these complications to more specialized care settings could result in improved delivery outcomes.

Reducing perinatal mortality in Vila Central Hospital, Vanuatu

This paper provides accurate figures and detailed analysis of the causes of perinatal mortality in the main referral hospital in Vanuatu in 1992, and discusses possible improvements in management. The perinatal mortality rate for the Vila Central Hospital area was 30.4 per 1000 births (with a stillbirth rate of 14 per 1000). These figures include mothers who presented for the first time in labour without any antenatal care, and cases of very low birthweight (less than 1 kg). These results were achieved with very low intervention rates. The commonest cause of death in Vanuatu was birth asphyxia, with prematurity, unexplained stillbirth and major congenital abnormality as the other main causes. Even though there is still scope for improvement, especially in the prevention of birth asphyxia, the perinatal mortality rate in Vanuatu compares favourably with that in other developing countries. Increased family planning uptake will be expected to lead to a reduction in perinatal mortality.

A comparison between health centre deliveries and deliveries born before arrival in the Aitape district

In this survey the obstetric and neonatal data of the admissions to the Obstetric Ward in Raihu Health Centre during 1990, 1991 and the first half of 1992 were analyzed. The emphasis of the survey was on the difference between deliveries born before arrival (BBA) (24%) and health centre (HC) deliveries (76%). The survey shows that there were differences in postnatal complications, postpartum haemorrhage (16% vs 4.3%), retained placenta (21% vs 1.3%) and puerperal sepsis (18% vs 4.3%), and in antenatal attendance (52% vs 90%), average bedstay (6.5 days vs 5.4 days), mean haemoglobin level (7.78 vs 8.77 g/dl) and gonorrhoea (17% vs 8%). For the neonatal data the survey shows differences in stillbirth rate (10.5% vs 2.3%), perinatal death in the first week (4.0% vs 2.5%) and mean birthweight (for male infants 2.75 kg vs 2.88 kg and female infants 2.60 kg vs 2.73 kg).

Induction of labor with intravaginal misoprostol in intrauterine fetal death

OBJECTIVE

Our purpose was to evaluate the effectiveness and safety of intravaginal misoprostol for the induction of labor in intrauterine fetal death.

STUDY DESIGN

Seventy-two women at 18 to 40 weeks of pregnancy with intrauterine fetal death, without abdominal scars, were treated with 100 micrograms of intravaginal misoprostol. The dose was repeated every 12 hours until effective uterine contractions and cervical dilatation were obtained, for up to 48 hours.

RESULTS

The mean time from induction to delivery was 12.6 hours, and only six patients (8%) required between 24 and 48 hours, at the end of which all patients had been delivered. Only the Bishop's score was significantly associated with time from first dose to expulsion. No surgical procedure was required. Hypercontractility, sweating, fever, diarrhea, or other gastrointestinal effects were not detected. There was no need for analgesics.

CONCLUSIONS

Intravaginal misoprostol at the dose of 100 micrograms every 12 hours appears to be a safe, effective, practical, and inexpensive new method for induction of labor in intrauterine fetal death.

Association of time to pregnancy and the outcome of pregnancy

OBJECTIVE

To examine the relationship of subfertility with miscarriage, low birth weight, and preterm delivery.

DESIGN

Comparison of time to pregnancy distributions between pregnancies that had different outcomes. Three comparisons were made: (a) miscarriages with live births; within live births, (b) low birth weight infant (up to 2,500 grams) or not low birth weight; (c) preterm birth (37 weeks or less) or not preterm. Cox regression was used to adjust for covariates.

POPULATION

All first pregnancies were analyzed from the National Child Development Study, a large survey of young adults aged 33 years, which is nationally representative of the British-born population.

MAIN OUTCOME MEASURES

The distribution of the time taken to conceive (time to pregnancy), miscarriage, birth weight, and preterm delivery.

RESULTS

Pregnancies that ended in miscarriage tended to take 23% longer to conceive, after adjustment for the other variables. Pregnancies that resulted in preterm delivery tended to take 15% longer to conceive. There was no statistically significant association with low birth weight.

CONCLUSIONS

Delay in time to conception is a risk factor for poor obstetric outcome, irrespective of medical intervention.