Perinatal Mortality in Rift Valley Provincial General Hospital between May and October

2014

Mark MaugoFELTP

University of NairobiMBChB Level V

From Invisible to Visible

• “Absence of consistent periodic estimates leads to invisibility, and invisibility contributes to inaction”

Lawn, J. E., S. Cousens, et al. (2005). "4 million neonatal deaths: when? Where? Why?" Lancet 365(9462): 891-900

• Unsatisfactory effort put towards capturing this event

• District Health Information System- vital but still lacks the necessary information and analysis to explain the numbers

“Perinatal mortality is a key indicator of the health status and socio-economic development of a community”

World Health Organization, 1996

Why perinatal mortality?

Burden of perinatal mortality

• 10 per 1000 total births high income countries• 50 per 1000 total births low income countries

Neonatal and perinatal mortality: Country, Regional and Global Estimates. World Health Organization, 2006

Kenya• 37 per 1000 total births (Number could still be

higher considering the number of perinatal deaths that go unreported due to poor perinatal surveillance)

Kenya Demographic and Health Survey 2008-09

Study objectives

• To determine the causes and perinatal mortality rate in Rift Valley Provincial General Hospital

• To describe characteristics of the perinatal deaths observed in the hospital

Study methods

• Study site: Rift Valley Provincial General Hospital (RVPGH)

• Descriptive retrospective hospital-based study• Perinatal deaths in a six month period between

May 2014-October 2014• Ministry of Health-Perinatal Death Review Form

• Analysis done using Epi-Info 7 (CDC, Atlanta, USA)

Case definition

• Stillbirth defined as fetal death more than or equal to 28 weeks gestation

• Early neonatal death defined as death occurring in the first seven days of birth

Results

Results

4683 total births during that periodPerinatal Mortality Rate of 47.4 per 1000 total births

222 perinatal deaths88 stillbirths (40.1%) 134 early neonatal deaths

(59.9%)

241 Records Collected222 records analyzed 19 records did not meet the

exclusion criteria

Stillbirths in developing countries still invisible to existing perinatal surveillance

Characteristics of perinatal deaths

Causes of early neonatal death

Cumulative probability of causes of early neonatal death by age of death in RVPGH

between May 2014-Oct 2014

1 2 3 4 5 6 70%

20%

40%

60%

80%

100%

Prematurity and low birth weightBirth asphyxiaSepsisCongenital anomalies

Age of death(days)

Cu

mu

lati

ve p

rob

-ab

ilit

y

Distribution of perinatal deaths by age after birth in RVPGH between May and October 2014

Low birth weight and prematurity

• 151 (67.7%) of the perinatal deaths weighed less than 2500g

• Mean gestational age was 34.5 weeks

Antenatal Care

• 77.3 % of the mothers attended Antenatal care clinic

• Only 45.2% completed the four recommended visits

• 52% of the stillbirths were macerated suggesting an antenatal problem.(Fresh still births reflect quality of intrapartum care)

McCaw Binns A, Greenwood R, Ashley D, Golding J: Antenatal and Perinatal-Care in Jamaica -do They Reduce Perinatal Death Rates?Paediatric Perinatal Epidemiology1994, 8(Suppl 1):86-9

Partograph use

• Partograph use was poor with only 52.7% reported usage

• Use of WHO partograph in 8 hospitals in Indonesia, Malaysia and Thailand reduced postpartum infections (by 59%) and the number of stillbirths

WHO partograph cuts complications of labour and childbirth. Safe Mother1994 Jul-Oct;(15):10

Labour complications

• 93% of stillbirths were related with labour conditions compared with 34% in early neonatal deaths

• For the early neonatal deaths, the major complications were found to be premature rupture of membranes (PROM)followed by meconium stained liquor(MSL)

• Consistent with the large population-based study done by Lawn et al. which found MSL (11.5X) and PROM (1.8-6.7X) as important factors for neonatal and perinatal death

Lawn, J. E., S. Cousens, et al. (2005). "4 million neonatal deaths: when? Where? Why?" Lancet 365(9462): 891-900

Three Delay Model

Three levels of delay identified in the perinatal deaths that occurred in RVPGH

between May and October 2014

Limitations

• Incomplete records• Possible reporting bias

Conclusion

• Perinatal mortality rate was higher than national estimates

• Prematurity, low birth weight, birth asphyxia and sepsis are the three top causes of perinatal death

• Failure to recognize danger signs was the most common delay identified in seeking health care.

Recommendations

• More facility-based studies to be carried out to improve perinatal surveillance

• Improvement in data quality and records to ensure valid conclusions are drawn from them

• Analytical studies to test out the characteristics identified in the study

• Antenatal care should address the first level of delay

Acknowledgements

1) Field Epidemiology and Lab Training Program(FELTP)

2) Centers for Disease Control and Prevention3) The University of Nairobi, Faculty of Medicine4) Rift Valley Provincial General Hospital

Thank You