Risk and burden of adverse intrapartum-related outcomes associated with non-cephalic and multiple birth in rural Nepal: a prospective cohort study

Causes and age of neonatal death and associations with maternal and newborn care characteristics in Nepal: a verbal autopsy study

BACKGROUND

In Nepal, neonatal mortality fell substantially between 2000 and 2018, decreasing 50% from 40 to 20 deaths per 1,000 live births. Nepal's success has been attributed to a decreasing total fertility rate, improvements in female education, increases in coverage of skilled care at birth, and community-based child survival interventions.

METHODS

A verbal autopsy study, led by the Integrated Rural Health Development Training Centre (IRHDTC), conducted interviews for 338 neonatal deaths across six districts in Nepal between April 2012 and April 2013. We conducted a secondary analysis of verbal autopsy data to understand how cause and age of neonatal death are related to health behaviors, care seeking practices, and coverage of essential services in Nepal.

RESULTS

Sepsis was the leading cause of neonatal death (n=159/338, 47.0%), followed by birth asphyxia (n=56/338, 16.6%), preterm birth (n=45/338, 13.3%), and low birth weight (n=17/338, 5.0%). Neonatal deaths occurred primarily on the first day of life (27.2%) and between days 1 and 6 (64.8%) of life. Risk of death due birth asphyxia relative to sepsis was higher among mothers who were nulligravida, had <4 antenatal care visits, and had a multiple birth; risk of death due to prematurity relative to sepsis was lower for women who made ≥1 delivery preparation and higher for women with a multiple birth.

CONCLUSIONS

Our findings suggest cause and age of death distributions typically associated with high mortality settings. Increased coverage of preventive antenatal care interventions and counseling are critically needed. Delays in care seeking for newborn illness and quality of care around the time of delivery and for sick newborns are important points of intervention with potential to reduce deaths, particularly for birth asphyxia and sepsis, which remain common in this population.

Determinants of adverse birth outcome in Sub-Saharan Africa: analysis of recent demographic and health surveys

Background

More than 75% of neonatal deaths occurred in the first weeks of life as a result of adverse birth outcomes. Low birth weight, preterm births are associated with a variety of acute and long-term complications. In Sub-Saharan Africa, there is insufficient evidence of adverse birth outcomes. Hence, this study aimed to determine the pooled prevalence and determinants of adverse birth outcomes in Sub-Saharan Africa.

Method

Data of this study were obtained from a cross-sectional survey of the most recent Demographic and Health Surveys (DHS) of ten Sub-African (SSA) countries. A total of 76,853 children born five years preceding the survey were included in the final analysis. A Generalized Linear Mixed Models (GLMM) were fitted and an adjusted odds ratio (AOR) with a 95% Confidence Interval (CI) was computed to declare statistically significant determinants of adverse birth outcomes.

Result

The pooled prevalence of adverse birth outcomes were 29.7% (95% CI: 29.4 to 30.03). Female child (AOR = 0.94, 95%CI: 0.91 0.97), women attended secondary level of education (AOR = 0.87, 95%CI: 0.82 0.92), middle (AOR = 0.94,95%CI: 0.90 0.98) and rich socioeconomic status (AOR = 0.94, 95%CI: 0.90 0.99), intimate-partner physical violence (beating) (AOR = 1.18, 95%CI: 1.14 1.22), big problems of long-distance travel (AOR = 1.08, 95%CI: 1.04 1.11), antenatal care follow-ups (AOR = 0.86, 95%CI: 0.83 0.86), multiparty (AOR = 0.88, 95%CI: 0.84 0.91), twin births (AOR = 2.89, 95%CI: 2.67 3.14), and lack of women involvement in healthcare decision-making process (AOR = 1.10, 95%CI: 1.06 1.13) were determinants of adverse birth outcomes.

Conclusion

This study showed that the magnitude of adverse birth outcomes was high, abnormal baby size and preterm births were the most common adverse birth outcomes. This finding suggests that encouraging antenatal care follow-ups and socio-economic conditions of women are essential. Moreover, special attention should be given to multiple pregnancies, improving healthcare accessibilities to rural areas, and women’s involvement in healthcare decision-making.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11113-z.

Predictors of neonatal mortality: development and validation of prognostic models using prospective data from rural Bangladesh

Objective

To assess the extent to which maternal histories of newborn danger signs independently or combined with birth weight and/or gestational age (GA) can capture and/or predict postsecond day (age>48 hours) neonatal death.

Methods

Data from a cluster-randomised trial conducted in rural Bangladesh were split into development and validation sets. The prompted recall of danger signs and birth weight measurements were collected within 48 hours postchildbirth. Maternally recalled danger signs included cyanosis (any part of the infant's body was blue at birth), non-cephalic presentation (part other than head came out first at birth), lethargy (weak or no arm/leg movement and/or cry at birth), trouble suckling (infant unable to suckle/feed normally in the 2 days after birth or before death, collected 1-month postpartum or from verbal autopsy). Last menstrual period was collected at maternal enrolment early in pregnancy. Singleton newborns surviving 2 days past childbirth were eligible for analysis. Prognostic multivariable models were developed and internally validated.

Results

Recalling ≥1 sign of lethargy, cyanosis, non-cephalic presentation or trouble suckling identified postsecond day neonatal death with 65.3% sensitivity, 60.8% specificity, 2.1% positive predictive value (PPV) and 99.3% negative predictive value (NPV) in the development set. Requiring either lethargy or weight <2.5 kg identified 89.1% of deaths (at 39.7% specificity, 1.9% PPV and 99.6% NPV) while lethargy or preterm birth (<37 weeks) captured 81.0% of deaths (at 53.6% specificity, 2.3% PPV and 99.5% NPV). A simplified model (birth weight, GA, lethargy, cyanosis, non-cephalic presentation and trouble suckling) predicted death with good discrimination (validation area under the receiver-operator characteristic curve (AUC) 0.80, 95% CI 0.73 to 0.87). A further simplified model (GA, non-cephalic presentation, lethargy, trouble suckling) predicted death with moderate discrimination (validation AUC 0.74, 95% CI 0.66 to 0.81).

Conclusion

Maternally recalled danger signs, coupled to either birth weight or GA, can predict and capture postsecond day neonatal death with high discrimination and sensitivity.

Breech presentation delivery care: A review of childbirth semiology, mechanism and care

Objective

To review the concepts underlying breech presentation delivery as well as the semiology and the obstetric maneuvers contributing to a successful perinatal maternal outcome.

Materials and methods

Based on a hypothetical scenario to set the stage for a practical approach to the topic, an explanatory paper built on a narrative review is created in order to examine the principles related to diagnosis, mechanism of delivery and maternal care, emphasizing maneuvers to ease fetal extraction.

Results

Breech presentation delivery must be managed through the vaginal canal when already in the expulsion phase with fetal engagement. For diagnosis and care, it is essential to know the unique semiology and physiology of this condition as well as the obstetric maneuvers to facilitate an uncomplicated delivery.

Results

The mechanism of childbirth in breech presentation is complex and requires knowledge of its physiology and multiple obstetric maneuvers on the part of the obstetrician as well as the general practitioner, in order to ensure adequate care when there is no other option.

Maternal and foetal medical conditions during pregnancy as determinants of intrapartum stillbirth in public health facilities of Addis Ababa: a case-control study

Introduction

globally, intrapartum stillbirth accounts for 1 million deaths of babies annually, representing approximately one-third of global stillbirth toll. Intrapartum stillbirth occurs due to causes ranging from maternal medical and obstetric conditions; access to quality obstetric care services during pregnancy; and types, timing and quality of intrapartum care. Different medical conditions including hypertensive & metabolic disorders, infections and nutritional deficiencies during pregnancy are among risk factors of stillbirth. Ethiopia remains one of the 10 high-burden stillbirth countries with estimated rate of more than 25 per 1000 births.

Methods

a case-control study using primary data from chart review of medical records of women who experienced intrapartum stillbirth in 23 public health facilities of Addis Ababa during the period July 1, 2010 - June 30, 2015 was conducted. Data was collected from charts of all cases of intrapartum stillbirth meeting the inclusion criteria and randomly selected charts of controls in two to one (2:1) control to case ratio.

Results

chronic medical conditions including diabetes, cardiac and renal diseases were less prevalent (1%) among the study population whereas only 6% of women experienced hypertensive disorder during the pregnancy in review. Moreover, 6.5% of the study population had HIV infection where being HIV negative was protective against intrapartum stillbirth (aOR 0.37, 95% CI 0.18-0.78). Women with non-cephalic foetal presentation during last ANC visit were three times more at risk of experiencing intrapartum stillbirth whereas singleton pregnancy had strong protective association against intrapartum stillbirth (p<0.05).

Conclusion

untreated chronic medical conditions, infection, poor monitoring of foetal conditions and multiple pregnancy are among important risk factors for intrapartum stillbirth.

Perceptions, careseeking, and experiences pertaining to non-cephalic births in rural Sarlahi District, Nepal: a qualitative study

Background

In low-resource settings, a significant proportion of fetal, neonatal, and maternal deaths can be attributed to intrapartum-related complications. Certain risk factors, such as non-cephalic presentation, have a particularly high risk of complications. This qualitative study describes experiences around non-cephalic births and highlights existing perceptions and care-seeking behavior specific to non-cephalic presentation in rural Sarlahi District, Nepal.

Methods

We conducted in-depth interviews with 34 individuals, including women who recently gave birth to a non-cephalic infant and female decision-makers in their households. We also conducted two focus groups with mothers (have two or more children, with at least one child under age five) and two focus groups with grandmothers in the community.

Results

Several women described scenes of obstructed labor and practices like provision of unspecified injections early in labor to assist with the delivery. There were reports of arduous care-seeking processes from primary health centers to tertiary facilities, and mixed quality of care among home birth attendants and facility-based health workers respectively. Very few women were aware of the fetal presentation prior to delivery, and we identified no consistent understanding among participants of the risks of and care strategies for non-cephalic births. Risk perception around non-cephalic presentation varied widely. Some participants were acutely aware of potential dangers, while others had not heard of non-cephalic birth. Many interviewees said that the position in which a pregnant woman sleeps could impact the fetal position. Several participants had either taken or heard of medication intended to rotate the fetus into the correct position.

Conclusions

Our findings suggest the mixed quality of and access to care associated with non-cephalic birth and a lack of consistent understanding of the risk of and care for non-cephalic births in rural Nepal. The high risk of the condition and the recommended tertiary care present a dilemma in low-resource settings; the logistical difficulties and the mixed quality of care make care-seeking and referral decisions complex. While public health stakeholders strive to improve the quality of and access to the formal health system, those players must also be sensitive to the potential negative implications of promoting institutional care-seeking.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1724-2) contains supplementary material, which is available to authorized users.