The determinants of infant mortality in Malaysia: a graphical chain modelling approach

"A graphical chain modelling approach is used to study the determinants of neonatal and post-neonatal mortality in Malaysia. This approach provides an easily interpretable empirical description and illustrates explicitly the conditional independence structure between each pair of variables. The interpretation can be read directly from a mathematical graph. Besides examining the direct association of each determinant on mortality, we also examine the effects of socio-economic determinants on intermediate determinants to understand the pathways through which the socioeconomic determinants affect the chance of mortality. The data anlaysed come from the second Malaysian Family Life Survey, fielded between August 1988 and January 1989. "

Early neonatal morbidity and mortality in a city based medical college nursery

Early neonatal morbidity & mortality were studied in 7972 viable live born babies over one year period in Medical College, Calcutta. Early neonatal morbidity and mortality rate were 66.85 & 32.86 respectively. About 48% of Early neonatal deaths occurred in 1st 48 hours & 80% within first 72 hours of life. Early neonatal mortality rate per 1000 was maximum in babies born of a primi (43.03) and grand multiparous mother (103.89); maternal age less than 20 yrs. (44.15), and more than 30 yrs. (46.04) & in multiple pregnancy (142.85). It was highest in breech delivery (114.28) & with maternal disease like dribling (179), hypertension (146) & APH (116). Birth asphyxia contributed 65.26% of early neonatal deaths, followed by septicaemia (10.3%). Klebsiella was the most common (55%) organism.

Why perinatal mortality cannot be a proxy for maternal mortality

In recent years, the perinatal mortality rate (PNMR) has been proposed as a proxy measure of maternal mortality, because perinatal deaths are more frequent and potentially more easily measured. This report assesses evidence for an association between these two statistics. This study, based upon data from Matlab, Bangladesh, shows that the maternal mortality ratio (MMR) and the PNMR do not vary together over time, and that the PNMR does not reliably indicate either the magnitude or the direction of change in the MMR from year to year. Statistical analysis shows that the correlation between the PNMR and the MMR is not significantly different from zero. An examination of the major causes of maternal and perinatal deaths indicates that the two measures cannot be expected to vary together. Almost half of perinatal deaths result from causes that do not pose a threat to the mother's life, and almost half of maternal deaths result from causes that do not lead to perinatal death. Monitoring of the PNMR can give an inaccurate picture of maternal mortality and should not be used as a proxy.

Preterm singleton breech in North Jordan: vaginal versus abdominal delivery

The safety of vaginal birth for singleton preterm breech has not often been addressed before. We retrospectively compared the perinatal outcome of two groups of preterm breech delivery. Sixty-six patients delivered vaginally and 32 delivered abdominally between 26 and 36 completed weeks. Vaginal delivery was allowed under the same protocol for singleton breech delivery at term. Both groups had similar maternal characteristics. Intergroup differences in early neonatal outcome, as measured by Apgar score, were not significant. Intrapartum and early neonatal deaths in vaginal and cesarean delivery were compared. There was no significant difference in intrapartum death and early neonatal mortality between those who delivered vaginally and those who delivered by cesarean section (16.6 vs. 15.6%). So even with optimum neonatal care facilities, cesarean section does not offer any advantage over vaginal delivery in a developing country. This study does not advocate the routine use of cesarean section for delivering preterm breech fetuses.

Hypertensive disorders of pregnancy and maternal and foetal outcome: a case controlled study

A case controlled prospective study of 250 cases of hypertension complicating pregnancy (study group) and 400 normal pregnant women (control group) was carried out to determine the effect of hypertension on maternal and foetal outcome. Pregnancy induced hypertension was present in 96% cases and chronic hypertension in 4% cases. Preterm delivery (28.8% versus 3%), labour induction rate (52.8% versus 3.25%), caesarean section rate (14.8% versus 3.5%), stillbirth rate (4.8% versus 0.25%) and overall perinatal mortality rate (14.8% versus 1%) were higher in study group compared to controls. In study group (40%) babies required special nursery care compared to controls (6.75%). From these results it can be concluded that maternal hypertension is associated with adverse pregnancy outcome.

Using perinatal audit to promote change: a review

Close to half of all infant deaths world-wide now occur in the first week of life, almost all in developing countries, and the perinatal mortality rate (PNMR) is used as an indicator of the quality of health service delivery. Clinical audit aims to improve quality of care through the systematic assessment of practice against a defined standard, with a view to recommending and implementing measures to address specific deficiencies in care. Perinatal outcome audit evaluates crude or cause-specific PNMRs, reviewing secular trends over several years or comparing rates between similar institutions. However, the PNMR may not be a valid, reliable and sensitive indicator of quality of care at the institutional level in developing countries because of variations in the presenting case-mix, various confounding non-health service factors and the small number of deaths which occur. Process audit compares actual practice with standard (best) practice, based on the evidence of research or expert consensus. Databases reviewing the management of reproductive health problems in developing countries are currently being prepared so as to provide clinicians and health service managers with up-to-date information to support the provision of evidence-based care. Standard practice should be adapted and defined in explicit management guidelines, taking into account local resources and circumstances. Forms of process audit include the review of care procedures in cases which have resulted in a pre-defined adverse outcome, know as 'sentinel event audit'; and the review of all cases where a particular care activity was received or indicated, known as 'topic audit'. These are complementary and each depends on the quality of recorded data. The forum for comparing observed practice with the standard may be external, utilising an 'expert committee', or internal, in which care providers audit their own activities. Local internal audit is more likely to result in improvements in care if it is conducted in a structured and culturally sensitive way, and if all levels of staff are involved in reviewing activities and in formulating recommendations. However, further research is needed to identify the factors which determine the effectiveness and sustainability of perinatal audit in different developing country settings.

Impact of health centre availability on utilisation of maternity care and pregnancy outcome in a rural area of Haryana

Six hundred married women of 15-45 years age group were interviewed in 4 villages of the district Ambala in Haryana. Impact of health centre (HC) availability on the knowledge, opinion and practices related to maternity care and pregnancy outcome was assessed after adjusting the effect of socio-economic status. Except 17 women (2.8%), everyone knew at least one correct purpose of antenatal care (ANC) and 98.2% women had contacted health staff for ANC. However, knowledge of the respondents about the components of ANC was found to be poor in study villages. Traditional birth attendants (TBAs) conducted delivery in 76.1% cases in sub-centre (SC), 75.6% in villages without a HC compared to 49.8% in primary health centre (PHC) village. However, preference for TBAs in PHC village was 14.9%, in SC village 33.5%, and in villages without HC 36.3% (p < 0.001). Among respondents having better awareness about ANC components, preference and utilisation of modern delivery attendants was found to be higher. For maternity illnesses, consultation rate of government functionaries was 67.9% in PHC village, 52.2% in SC village and 55.8% in villages without a HC. Perinatal mortality rate of 76.0/1000 births in villages without HC was not significantly different from the rate of 87.4/1000 in SC village but rate of 38.9/1000 in the PHC village was significantly lower (p < 0.01). Awareness and availability of modern maternity services were found to have significant influence on the health seeking behaviour and pregnancy outcome.

Protective effects of topical antimicrobials against neonatal tetanus

BACKGROUND

Case-control studies previously conducted in Pakistan suggested that topical antimicrobials might provide protection against neonatal tetanus (NNT) when applied to the umbilical cord wound during the first several days of life. The present case-control study, the largest such study yet reported, was undertaken in Punjab Province, Pakistan and afforded further opportunities to evaluate such effects.

METHODS

A population-based, matched, case-control study was undertaken to assess topical antimicrobials and other factors related to NNT risk in rural parts of Punjab Province.

RESULTS

Continuous use of antimicrobial agents (antibiotics and antiseptics) at delivery and during the first few days after delivery was highly protective in univariate testing (matched odds ratio 0.2 [95% confidence interval: 0.11-0.64], P = 0.003), and remained significantly protective when other delivery and cord care practices were controlled. In contrast, applying nothing to the wound was risky compared with antimicrobial exposures. Hand washing and delivery by a trained birth attendant appeared protective. Application of animal dung or ash to the umbilical wound was hazardous. Similarly, predelivery cutaneous or intravaginal exposure of mothers to ghee (clarified butter) and delivery on a surface prepared with dried cow dung were risky, with significant interaction noted between them. Mortality and NNT were far more likely among previous births to mothers of cases.

CONCLUSIONS

Topical antimicrobials offer a new, effective and inexpensive means to prevent NNT, and could usefully complement maternal immunization with tetanus toxoid in controlling the disease. Special prevention efforts should be directed towards mothers of NNT cases.

Effect of cleansing the birth canal with antiseptic solution on maternal and newborn morbidity and mortality in Malawi: clinical trial

OBJECTIVE

To determine if cleansing the birth canal with an antiseptic at delivery reduces infections in mothers and babies postnatally.

DESIGN

Clinical trial; two months of no intervention were followed by three months of intervention and a final month of no intervention.

SETTING

Queen Elizabeth Central Hospital (tertiary care urban hospital), Blantyre, Malawi.

SUBJECTS

A total of 6965 women giving birth in a six month period and their 7160 babies.

INTERVENTION

Manual wipe of the maternal birth canal with a 0.25% chlorhexidine solution at every vaginal examination before delivery. Babies born during the intervention were also wiped with chlorhexidine.

MAIN OUTCOME MEASURES

Effects of the intervention on neonatal and maternal morbidity and mortality.

RESULTS

3635 women giving birth to 3743 babies were enrolled in the intervention phase and 3330 women giving birth to 3417 babies were enrolled in the non-intervention phase. There were no adverse reactions related to the intervention among the mothers or their children. Among infants born in the intervention phase, overall neonatal admissions were reduced (634/3743 (16.9%) v 661/3417 (19.3%), P < 0.01), as were admissions for neonatal sepsis (7.8 v 17.9 per 1000 live births, P < 0.0002), overall neonatal mortality (28.6 v 36.9 per 1000 live births, P < 0.06), and mortality due to infectious causes (2.4 v 7.3 per 1000 live births, P < 0.005). Among mothers receiving the intervention, admissions related to delivery were reduced (29.4 v 40.2 per 1000 deliveries, P < 0.02), as were admissions due to postpartum infections (1.7 v 5.1 per 1000 deliveries, P = 0.02) and duration of hospitalisation (Wilcoxon P = 0.008).

CONCLUSIONS

Cleansing the birth canal with chlorhexidine reduced early neonatal and maternal postpartum infectious problems. The safety, simplicity, and low cost of the procedure suggest that it should be considered as standard care to lower infant and maternal morbidity and mortality.

Impact of pregnancy on maternal AIDS

OBJECTIVE

To assess the impact of pregnancy on maternal acquired immunodeficiency syndrome (AIDS) among tribal women in India.

STUDY DESIGN

From February 1992 to February 1996, 71 tribal women from Manipur, India, with AIDS (Centers for Disease Control stage iii/iv), matched for age, parity, CD4 lymphocyte count and demographic characteristics, were recruited into a prospective study. Thirty-two (49%) of these women were pregnant (8-10 weeks) (group A) and 38 (51%) nonpregnant (group B).

RESULTS

Pneumocystis carinii pneumonia followed by miliary tuberculosis and wasting disease were the most common AIDS-defining illness and cause of maternal death in both groups. A total of 28 (39%) women died as a direct result of their AIDS-defining illness; 10 (27%) of them were among the nonpregnant women as compared to 18 (56%) deaths among the pregnant women (P = .17, odds ratio 3.7285, 95% confidence interval 1.23, 11.58). Three (16%) of these 18 deaths occurred within 14 weeks of an uneventful first-trimester medical termination of pregnancy. Thirteen women (41%) died undelivered at 30-34 weeks' gestation, and two died within 3 weeks of delivery. Fourteen (44%) women vaginally delivered 14 preterm infants, between 28 and 35 weeks' gestation. Eleven of these infants died within six weeks; nine deaths were a direct result of prematurity and clinical diagnosis of an AIDS-defining illness. The mean survival time was 9.72 months for the pregnant women and 22.6 months for the nonpregnant women (P = .066).

CONCLUSION

Pregnancy increased maternal and fetal mortality in these AIDS-infected women.

Neonatal sepsis in Addis Ababa, Ethiopia: a review of 151 bacteremic neonates

A retrospective study of 542 neonatal sepsis cases was undertaken. Bacteremia was confirmed in 151 cases. There were a total of 195 (36%) deaths. Fifty nine (39%) of the deaths were from the bacteremia cases. The incidence of sepsis was 11 per 1000 live births. Klebsiella was the leading etiologic agent (38%), with a mortality rate of 54%. Low birth weight was found to be a predisposing factor for the development of sepsis and mortality. The high incidence of sepsis, the increase in mortality rate and the spread of nosocomial infection is discussed.

Reducing perinatal mortality in developing countries

The perinatal mortality rate (PNMR) is a key health status indicator. It is multifactorial in aetiology and is significantly influenced by the quality of health care. While there is an ethical imperative to act to improve quality of care when deficiencies are apparent, the lack of controls--when an interventions is applied to an entire service--makes it difficult to infer a causal relationship between the intervention and any subsequent change in PNMR. However, by specifically measuring avoidable perinatal deaths (those due to error or omission on the part of the health service), this limitation is partially overcome, and the impact of the intervention can be more rigorously evaluated. This paper reports the impact of perinatal audit in a rural African health district between 1991 and 1995. A total of 21,112 consecutive births were studied: the average number of deliveries increased by 31% from 325 to 424 per month. The PNMR (birth weight > or = 1000g) in 1991 was 27/1000, increased to 42/1000 in 1992, and fell steadily to 26/1000 in 1995 (40% reduction; p = 0.002). The proportion of avoidable deaths fell from 19% in 1991 to zero in the second half of 1995 (p = 0.0008). While factors associated with perinatal mortality are many, complex, and interrelated, this report suggests that mortality can be reduced significantly in resource-poor settings by improving quality of health care. Including the measurement of avoidable deaths in perinatal audit allows the impact of interventions to be more rigorously assessed than by simple measuring the PNMR.

Perinatal mortality rates and associated socio-demographic factors in two rural districts in Zimbabwe

OBJECTIVE

To determine perinatal mortality rates and associated socio-demographic factors in two rural districts in Zimbabwe.

DESIGN

Cross sectional community based survey.

SETTING

Murewa and Madziwa rural districts.

SUBJECTS

Women aged 15 to 50 years who had been pregnant over the preceding two years before the study.

MATERIALS AND METHODS

A questionnaire was administered to eligible women by trained interviewers. Information pertaining to the women's socio-demographic characteristics, reproductive health profile and pregnancy outcome was documented. A post hoc case control analysis was undertaken to determine the risk factors associated with poor perinatal outcome. Women who had a poor perinatal outcome were designated cases and those with a good outcome were designated controls.

RESULTS

The average perinatal mortality rate for both districts was 111 per 1,000 live births (Murewa 182 per 1,000 and Madziwa 48 per 1,000). Factors significantly associated with perinatal mortality were ethnicity, marital status, subjective standard of living and the women's level of formal education. Being Zezuru or being married was associated with poor perinatal outcome. Living well and having high levels of education were also associated with poor perinatal outcome. Perinatal mortality was not significantly associated with maternal age or spouse level of education.

CONCLUSION

This study showed unacceptability high perinatal mortality rates in these rural districts. The true socio-demographic factors associated with perinatal mortality could not be ascertained in this study because of confounding factors. There is need to study quality of antenatal, intrapartum and neonatal care offered by health centres in these districts. In addition there is need to strongly advocate a perinatal programme to address these high mortality rates.

Reproductive pattern, perinatal mortality, and sex preference in rural Tamil Nadu, south India: community based, cross sectional study

OBJECTIVES

To study reproductive pattern and perinatal mortality in rural Tamil Nadu, South India.

DESIGN

Community based, cross sectional questionnaire study of 30 randomly selected areas served by health subcentres.

SETTING

Rural parts of Salem District, Tamil Nadu, South India.

SUBJECTS

1321 women and their offspring delivered in the 6 months before the interview.

MAIN OUTCOME MEASURES

Number of pregnancies, pregnancy outcome, spacing of pregnancies, sex of offspring, perinatal and neonatal mortality rates.

RESULTS

41% of the women (535) were primiparous; 7 women (0.5%) were grand multiparous (> 6 births). The women had a mean age of 22 years and a mean of 2.3 pregnancies and 1.8 live children. The sex ratio at birth of the index children was 107 boys per 100 girls. The stillbirth rate was 13.5/1000 births, the neonatal mortality rate was 35.3/1000, and the perinatal mortality rate was 42.0/1000. Girls had an excess neonatal mortality (rate ratio 3.42%; 95% confidence interval 1.68 to 6.98; this was most pronounced among girls born to multiparous women with no living sons (rate ratio 15.48 (2.04 to 177.73) v 1.87 (0.63 to 5.58) in multiparous women with at least one son alive).

CONCLUSIONS

In this rural part of Tamil Nadu, women had a controlled reproductive pattern. The excess neonatal mortality among girls constitutes about one third of the perinatal mortality rate. It seems to be linked to a preference for sons and should therefore be addressed through a holistic societal approach rather than through specific healthcare measures.

A study of the referral patterns of obstetric clinics and the performance of receiving neonatal intensive care units in Taiwan

To study the referral patterns of obstetric clinics, and the performance of receiving intensive care units measured by the survival of transported neonates, transport records were collected prospectively between July, 1991 and June, 1992. Two hundred and fifty-four transported neonates born in 51 obstetric clinics (level I units) in Tainan City and County, in southern Taiwan, were enrolled in this study. Nineteen percent of the transported neonates were very low birthweight infants (< 1500 g). Nearly equal numbers of them were transported to eight district hospitals (level II units) and to a tertiary center (level III unit), but these infants were 1.5 times more likely to die in a level II unit than a level III unit. In addition, equal numbers of infants assisted by mechanical ventilators were transported to level II and III units, but these infants were three times more likely to die in a level II unit than a level III unit (P = 0.006). Seventy-seven percent of the normal birthweight infants (> or = 2500 g) were transported to level II units, and the mortality in this group was 12.3% compared with 0% in those transported to the level III unit. Approximately 56% of these normal birthweight infants in level II units died of severe birth asphyxia. The referral patterns of level 1 units had an unfavorable effect on the survival of neonates requiring mechanical ventilation. Enhancing the skills of the staff in level I units to recognize and stabilize such infants, elevating the capability of level II units in treating some of these cases, and increasing the hospital beds for level III care are necessary to increase their chance of survival.

Neonatal nosocomial infection: profile and risk factors

OBJECTIVE

To determine the incidence and risk factors for neonatal nosocomial infections.

DESIGN

Cohort study.

SETTING

Tertiary care Teaching Hospital.

METHODS

Hospital born neonates transferred to the neonatal unit after birth and available in the unit 48 hours later comprised the cohort for the surveillance. Detailed maternal, intrapartum and neonatal variables were recorded. Risk factors for nosocomial infection were analyzed by both univariate and multiple logistic regression methods.

RESULTS

One hundred and thirty-four neonates were enrolled in the cohort. The overall nosocomial infection rate was 16.8/1000 patient days. Device associated infection rate was 11.9/1000 device days. Multidrug resistant Klebsiella species was the commonest organism causing nosocomial septicemia and pneumonia followed by Pseudomonas aeruginosa. The risk factors detected to be significantly associated with infection on multiple logistic regression analyses were a birth weight < 1500 g (OR 3.3) and assisted ventilation > 72 h (OR 14.2).

CONCLUSIONS

Very low birth weight (VLBW) neonates, especially those undergoing interventions such as mechanical ventilation are at the greatest risk for infection and death. Therefore, strict protocol for asepsis must be adhered to when handling these high risk infants.

A study of possible deleterious effects of consanguinity

The aim of the study was to determine whether consanguineous marriages result in reproductive wastage and an increased incidence of illness in the offspring in a community with a long history of inbreeding and an expected high rate of consanguineous marriage. A representative sample of 2200 women aged > or = 15 years from Dubai and Al Ain, two cities in the United Arab Emirates, representing on the one hand a modern metropolis and on the other a traditional society, were studied. A questionnaire, which included questions on age, parity, gravidity, number of stillbirths, number of abortions, number of children alive, neonatal deaths and specific illnesses in children, was administered by nurses in antenatal and gynaecological clinics in the two cities. The rate of consanguineous marriage was 50.5% and parity, gravidity, ages and number of children were similar in consanguineous and non-consanguineous groups. There was no significant difference in rates of abortion, stillbirth and neonatal death between the two groups. Overall, there was statistically significant higher reproductive wastage in consanguineous couples, but when the category of less than second cousins was excluded from the consanguineous group no difference was found in reproductive wastage between consanguineous and non-consanguineous marriages. Children born to consanguineous unions also had significantly higher incidences of illnesses (37.1%) than those of non-consanguineous unions (29%). The occurrence of malignancies, congenital abnormalities, mental retardation and physical handicap was significantly higher in offspring of consanguineous than non-consanguineous marriages. In conclusion, consanguinity did not result in reproductive wastage, but was found to be an important factor in the causation of specific illnesses in offspring.

Perinatal care in Pakistan: a situational analysis

Pakistan, one of the most populous countries in the world, has an estimated perinatal mortality rate of 60 to 90 per thousand births, of which almost half are stillbirths. Although infant mortality rates have declined in recent years, nearly 60% of all deaths occur in the neonatal period and have shown comparatively little change over several decades. This is attributed mainly to inadequate attention to programs of maternal and newborn care. The recently implemented Social Action and Health Care Programs of the Government of Pakistan promises to provide domiciliary maternal and newborn care services through the use of trained birth attendants and community workers. The primary health care services network is also being revamped in an effort to improve timely recognition of high-risk pregnancies and to facilitate prompt referral. The importance of the newborn period is also being emphasized in pediatric undergraduate and postgraduate training programs, as well as through continuing medical education. However, the most important long-term solution would be improvement in the educational and social status of women, as well as a greater political support for diversion of limited resources to appropriate primary and secondary health care.

Sex differentials in perinatal mortality in China and Finland

This study describes patterns of sex differentials in perinatal mortality in China and Finland. The analysis is based on three population-based one-year birth cohorts, one from Qingdao, China, in 1992 and two from Northern Finland in 1966 and 1985-86, comprised of 9,219, 11,422 and 9,207 singletons with at least 28 gestational weeks and 1000 g in birthweight, respectively. Both Finnish cohorts had an excess of male over female perinatal deaths, but in the Chinese cohort girls were more likely to die than boys. The adjusted odds ratio (OR) of perinatal mortality for boys was 1.31 (95 per cent confidence interval [CI] 0.98, 1.78) and 1.57 (95 per cent CI 0.89, 2.78) in the Finnish 1966 and 1985-86 cohorts, respectively, and 0.82 (95 per cent CI 0.55, 1.20) in the Chinese cohort. The corresponding figure for stillbirths in the Chinese was 0.57 (95 per cent CI 0.33, 0.98), which could explain the total excess of female deaths during the perinatal period. Our results suggest that the role of different social and cultural environments on the existing sex differentials in perinatal mortality between the countries needs further evaluation.