Further observations on ghee as a risk factor for neonatal tetanus

BACKGROUND

Previous case-control studies of neonatal tetanus (NNT) in the North West Frontier Province of Pakistan indicated that clarified butter (ghee) applied to the umbilical wound of newborns was a significant risk factor for NNT. However, the mechanisms underlying the risk remained undisclosed.

METHODS

A hospital-based case-control study was undertaken to evaluate further ghee and other factors possibly associated with risk of NNT. Mothers of several recent ghee-associated cases were visited in their homes, asked to simulate the procedures used in preparing the ghee, and samples of ghee were collected for culture.

RESULTS

Topical application of ghee to the umbilical wound was again shown to pose a significant risk for NNT. In-use contamination of ghee was documented as mothers repeatedly heated and manipulated samples of ghee set aside in special containers for this purpose. Ghee was usually applied to the umbilical wound of the baby several times each day for the first few days of life. Mothers of cases were again confirmed to be substantially more likely to report prior NNT cases than mothers of controls.

CONCLUSIONS

Educational interventions to reduce umbilical ghee use or to wash hands before each manipulation might reduce the risk of NNT in babies exposed to ghee who are born to non-immunized mothers. Increased efforts to immunize women of childbearing age with tetanus toxoid are also needed, with special priority for mothers known to have been associated with a previous NNT case. Topical antibiotics should be further evaluated for protective effects in non-immunized mothers.

[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.

Maternal care receptivity and its relation to perinatal and neonatal mortality. A rural study

A longitudinal study was conducted on 212 pregnant women from May 1987 to April 1988. Maternal Care Receptivity (MCR) "an innovative approach" was adopted for the assessment of maternal care services provided to pregnant mothers at their door steps. During follow-up, scores were allotted to each of the services rendered and antenatal status of pregnant women. Depending on the score--MCR was classified as high (11 to 8), moderate (7 to 4) or poor (3 to 0). Perinatal and neonatal deaths were recorded and an inverse relationship between MCR and perinatal and mortalities was observed (z = 5.46, p < 0.0001). Significantly, no perinatal or neonatal deaths occurred in women with high MCR. One of the most important cause of high PNMR and neonatal mortality rate in developing countries is poor MCR, i.e., under utilization of even the existing maternal health services. The main reasons for this under utilization appear to be poverty, illiteracy, ignorance and lack of faith in modern medicine.

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.

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.

Caesarean birth rates worldwide. A search for determinants

High caesarean birth rates are an issue of international public health concern. Determinants of caesarean birth are reviewed in order to formulate strategies to reduce these high rates. A strong independent profession of highly qualified midwives, who care for women with low-risk pregnancies, may contribute to a relatively low caesarean birth rate. Different clinical policies which influence the intervention rate, are discussed for the most frequent reasons to perform caesarean section: dystocia, repeat caesarean birth, breech delivery and foetal distress. The risks and safety of caesarean birth differ from place to place in this world. As the relative safety of the procedure is an important factor contributing to the rise of caesarean birth, the fact that this has only been achieved in some parts of the world should restrict the indications to perform the operation in the best interests of pregnant women.

Variations in pregnancy outcomes by race among 10-14-year-old mothers in the United States

This study used the 1983-86 U.S. Linked Live Birth-Infant Death Files to examine variations in pregnancy outcomes among 38,551 U.S. resident black and white adolescents ages 10 through 14. The birth rate was 4.29 per 1,000 for blacks, more than 7 times the rate for whites (.59 per 1,000). Black mothers had higher proportions of very low and low birth weight infants than did whites (very low birth weight: 3.7 versus 2.6; low birth weight: 15.0 versus 10.5). Neonatal and infant mortality rates were higher among very low birth weight and low birth weight white infants. Neonatal and infant mortality rates were similar for normal birth weight infants of both races, but were 3.7 to 7.4 times higher among black infants with birth weights more than 4,250 grams. Logistic regression indicated that black mothers were at higher risk for having infants who were low birth weight, very low birth weight, small for gestational age, preterm, and very preterm. There were no differences by race for neonatal, postneonatal, and infant mortality. While the risk for poor pregnancy outcomes is great among young adolescents, young black adolescents appear to be particularly vulnerable. Attempts to reduce unintended pregnancies in this group should receive highest priority.

Age variations in the proximate determinants of child mortality in south-west Nigeria

Age variations in the influences of three sets of proximate factors on child survival in Ondo State, Nigeria, during 1981-86 are described. Biodemographic factors covary very strongly with mortality risks during the first month of life, weakly during months 1-11, and imperceptibly beyond infancy. Microenvironmental factors progressively strongly covary with mortality after the neonatal period, while health services accessibility and care factors broadly covary strongly with mortality throughout early childhood. Patterns in the size of the hypothetical population-level impacts of these factors suggest that promoting assisted use of toilet facilities within households by under-5s and wider provision of dispensaries and hospitals would yield cost-effective and notable reductions in overall childhood mortality levels in the study setting.

Determinants of infant mortality in Malawi: an analysis to control for death clustering within families

The 1988 Malawi Traditional and Modern Methods of Child Spacing Survey data are used to identify determinants of infant mortality in Malawi. The logistic binomial analysis shows that socioeconomic factors are significant even during the neonatal period while the length of the preceding birth interval is significant in the post-neonatal period only. There is a strong familial correlation of mortality risks during both the neonatal and post-neonatal periods but the effect of geographical area of residence is stronger in the post-neonatal period.

A multicentre study of perinatal mortality in Nepal

A prospective survey was carried out in two Kathmandu hospitals and two rural districts to establish urban and rural perinatal mortality rates (PNMRs) for these four centres in Nepal and to ascertain the causes of perinatal mortality. All perinatal deaths occurring over a 1-year period in the four centres were included (during which time there was a total of 14,967 births). Cause of death was established by contemporary review of hospital case records or by structured questionnaire ('verbal autopsy') in the rural areas. The PNMRs in the hospitals were 48.0 and 23.7 per thousand total births respectively, whilst those of the rural settings were 96.2 and 42.5 per thousand births. Perinatal asphyxia, low birthweight and infection were the most common causes but many of the deaths were unexplained. The high mortality rates were felt to reflect the difficult circumstances of childbirth in Nepal. It was concluded that a number of interventions would appear appropriate, but that these should be introduced in a scientific manner.

The relationship between structural and health services variables and state-level infant mortality in the United States

OBJECTIVES

This study compared the relative strength of the associations of a set of structural (social, economic, and political) variables and a set of health services variables with state-level infant, neonatal, and postneonatal mortality. It also examined whether health services mediate the relationships between structural variables and state-level infant, neonatal, and postneonatal mortality.

METHODS

With the state as the unit of analysis, data for all 50 states were analyzed by means of multiple regression.

RESULTS

Structural variables accounted for substantially more variance in infant, neonatal, and postneonatal mortality than health services variables, and health services variables were more strongly related to infant mortality than to neonatal or postneonatal mortality. When health services variables were controlled, the strengths of the associations between the structural variables and infant, neonatal, and postneonatal mortality were reduced but remained statistically significant.

CONCLUSIONS

A substantial portion of the variance in state-level infant mortality is accounted for by states' structural characteristics, which are partially mediated by health services.

Impact of induced abortions and statistical definitions on perinatal mortality figures

Two problems originating from the advanced use of medical technology in screening for malformations and in the care of preterm and low birthweight infants are presented: the impact of the increasing number of induced medical abortions and the differences in statistical definitions on perinatal mortality (PNM) figures. Data on 186,562 births registered in the Finnish Medical Birth Registry between 1987 and 1989 were studied, and 65,554 medical abortions (of which 1647 were performed after the sixteenth week of gestation) registered in the Abortion Registry between 1985 and 1990. A 115% increase in abortions for medical reasons in the period 1985-1990 was found. It was estimated that the trend accounted for up to one-third of the decline in PNM rate during that time. The perinatal mortality rate was strongly influenced by very small infants. The application of the Finnish version of the International Classification of Diseases, Ninth Revision (ICD-9) (including all livebirths and using both birthweight of 500 g and gestational age of 22 weeks as the criteria) resulted in PNM rates which were about 5% higher than according to ICD-9. We suggest that the impact of medical abortions on perinatal statistics has reduced the value of the perinatal mortality rate as an indicator of the standard of care.

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.

Outcome in relation to Apgar score in term neonates

Sixty four asphyxiated term babies (Apgar score of 6 or less at 5 minutes) and 90 non-asphyxiated term babies (controls) were studied. Of these, 40 cases and 48 controls could be followed up. Mortality and neurodevelopmental outcome were studied in both the cases and controls. Mortality and poor neurodevelopmental outcome correlated inversely with the Apgar scores at 5 and 10 minutes. The outcome of babies with low 5 minute Apgar scores was significantly better than those with the same scores at 10 minutes. Symptomatic neonates when compared to asymptomatic neonates with same Apgar score showed significantly poorer outcome. Babies with Apgar scores of 6 at 5 or 10 minutes behaved like the controls both in terms of mortality and neurodevelopmental outcome.

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).