The epidemiology of perinatal death in Jamaica

Association of maternal history of neonatal death with subsequent neonatal death across 56 low- and middle-income countries

Early identification of high-risk pregnancies can reduce global neonatal mortality rate. Using the most recent Demographic and Health Surveys from 56 low- and middle-income countries, we examined the proportion of mothers with history of neonatal deaths. Logistic regression models were used to assess the association between maternal history of neonatal death and subsequent neonatal mortality. The adjusted models controlled for socioeconomic, child, and pregnancy-related factors. Country-specific analyses were performed to assess heterogeneity in this association across countries. Among the 437,049 live births included in the study, 6910 resulted in neonatal deaths. In general, 22.4% (1549) occurred to mothers with previous history of neonatal death; at the country-level, this proportion ranged from 1.2% (95% confidence interval [CI] 0.0, 2.6) in Dominican Republic to 38.1% (95% CI 26.0, 50.1) in Niger. Maternal history of neonatal death was significantly associated with subsequent neonatal death in both the pooled and the subgroup analyses. In the fully adjusted model, history of neonatal death was associated with 2.1 (95% CI 1.9, 2.4) times higher odds of subsequent neonatal mortality in the pooled analysis. We observed large variation in the associations across countries ranging from fully adjusted odds ratio (FAOR) of 0.4 (95% CI 0.0, 4.0) in Dominican Republic to 16.1 (95% CI 3.6, 42.0) in South Africa. Our study suggests that maternal history of neonatal death could be an effective early identifier of high-risk pregnancies in resource-poor countries. However, country-specific contexts must be considered in national policy discussions.

Association of Maternal History of Neonatal Death With Subsequent Neonatal Death in India

IMPORTANCE

Among the United Nations' Sustainable Development Goals is to reduce the neonatal mortality rate to 12 per 1000 live births by 2030. Identifying high-risk pregnancies can help achieve this target in low-resource countries, such as India, which accounts for one-fourth of global neonatal deaths.

OBJECTIVE

To analyze the association of maternal history of neonatal death with subsequent neonatal mortality.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included a nationally representative sample of singleton live births from multiparous women. Data were obtained from the 2016 National Family Health Survey in India. Data were analyzed from November 2018 to January 2020.

EXPOSURES

Maternal history of neonatal death and a comprehensive set of covariates, including socioeconomic environment, maternal anthropometry, and pregnancy care.

MAIN OUTCOMES AND MEASURES

Subsequent neonatal mortality. Population-attributable risk associated with history of neonatal death was calculated, and sensitivity analyses were performed.

RESULTS

The overall study population consisted of 127 336 singleton live births from multiparous women aged 15 to 49 (mean [SD] age, 28.8 [5.2] years) years when the survey was undertaken. In our analytic sample, 11 101 (8.7%) mothers had a history of neonatal death, and 506 of 2224 total neonatal deaths (22.8%) were attributed to women with history of neonatal death. The prevalence of history of neonatal death differed by selected covariates and across states or union territories. Maternal history of neonatal death was associated with significantly higher odds of neonatal mortality (adjusted odds ratio, 2.23; 95% CI, 1.96-2.55), and this remained consistent across different subgroups. The population-attributable risk associated with maternal history of neonatal death was 11.8%. Stronger associations were found for maternal history of multiple neonatal deaths (adjusted odds ratio, 3.50; 95% CI, 2.78-4.41) and in respect to the risk of mortality in early neonatal period (ie, 0-2 completed days) (adjusted odds ratio, 2.45; 95% CI, 2.09-2.86).

CONCLUSIONS AND RELEVANCE

These findings suggest that maternal history of neonatal death is a potentially useful risk factor to identify women and neonates who may need extended and enhanced pregnancy care.

Combined iron/folic acid supplements and malaria prophylaxis reduce neonatal mortality in 19 sub-Saharan African countries

BACKGROUND

In nonmalaria regions, iron/folic acid supplementation during pregnancy protects newborns against preterm delivery and early neonatal death. Other studies from malaria-endemic areas have reported an adverse effect of iron supplements on malaria prevalence in pregnant women.

OBJECTIVE

We examined the association between iron/folic acid supplements and prenatal antimalaria prophylaxis on neonatal mortality in malaria-endemic countries of sub-Saharan Africa.

DESIGN

This analysis used the most recent data from Demographic and Health Surveys of 19 malaria-endemic countries in sub-Saharan Africa. Survival information of 101,636 singleton live-born infants from the most recent delivery of ever-married women < or =5 y before each survey was examined. The effect of each potential predictor on neonatal deaths was analyzed by using Cox proportional hazards regression models.

RESULTS

Infants whose mothers received any iron/folic acid supplements and sulfadoxine-pyrimethamine intermittent preventive treatment (SP-IPT(p)) for malaria during pregnancy were significantly protected from neonatal death [hazard ratio (HR): 0.76; 95% CI: 0.58, 0.99]. The protective effect was not significant in mothers who received only iron/folic acid supplements (HR: 0.90; 95% CI: 0.73, 1.12) or only SP-IPT(p) (HR: 1.08; 95% CI: 0.74, 1.57). Among the sociodemographic and birth characteristics, factors that significantly increased the risk of neonatal death included first-born infants, a birth interval of <2 y, maternal age at delivery of > or =30 y, smaller than average-sized infants, and male infants.

CONCLUSION

The use of antenatal iron/folic acid supplements combined with appropriate intermittent preventive treatment of malaria during pregnancy is an important intervention to reduce neonatal mortality in malaria-endemic regions.

Impact of the Jamaican birth cohort study on maternal, child and adolescent health policy and practice

The Jamaica Perinatal Morbidity and Mortality Survey (JPMMS) was a national study designed to identify modifiable risk factors associated with poor maternal and perinatal outcome. Needing to better understand factors that promote or retard child development, behaviour and academic achievement, we conducted follow-up studies of the birth cohort. The paper describes the policy developments from the JPMMS and two follow-up rounds. The initial study (1986-87) documented 94% of all births and their outcomes on the island over 2 months (n = 10 508), and perinatal (n = 2175) and maternal deaths (n = 62) for a further 10 months. A subset of the birth cohort, identified by their date of birth through school records, was seen at ages 11-12 (n = 1715) and 15-16 years (n = 1563). Findings from the initial survey led to, inter alia, clinic-based screening for syphilis, referral high-risk clinics run by visiting obstetricians, and the redesign and construction of new labour wards at referral hospitals. The follow-up studies documented inadequate academic achievement among boys and children attending public schools, and associations between under- and over-nutrition, excessive television viewing (>20 h/week), inadequate parental supervision and behavioural problems. These contributed to the development of a television programming code for children, a National Parenting Policy, policies aimed at improving inter-sectoral services to children from birth to 5 years (Early Childhood Commission) and behavioural interventions of the Violence Prevention Alliance (an inter-sectoral NGO) and the Healthy Lifestyles project (Ministry of Health). Indigenous maternal and child health research provided a local evidence base that informed public policy. Collaboration, good communication, being vigilant to opportunities to influence policy, and patience has contributed to our success.

Perinatal audit using the 3-delays model in western Tanzania

OBJECTIVE

To audit intrapartum fetal and early neonatal deaths of infants weighing >or=2000 g in a regional hospital in western Tanzania.

METHODS

The 3-delays methodology was applied to a cohort of perinatal deaths from July 2002 to July 2004.

RESULTS

The overall perinatal mortality rate in the hospital was 38 per 1000 live births, and in just over half of these cases the birth weight was >or=2000 g. The leading clinicopathologic causes of death were birth asphyxia (19.0%), prolonged or obstructed labor (18.5%), antepartum hemorrhage (11.5%), and uterine rupture (9.0%). First delays occurred in 19.0% of the cases, second delays occurred in 21.5%, and third delays occurred in 72.5%.

CONCLUSION

For women who delivered in this hospital, most of the substandard care occurred after admission to the health facility. The improvement of institutional health care may have a significant impact on the decision to attend health institutions and, thereby, reduce first delays.

Four million neonatal deaths: counting and attribution of cause of death

Each year there are an estimated four million neonatal deaths and at least 3.2 million stillbirths. Three-quarters of the world's neonatal deaths are counted only through five-yearly retrospective household surveys. Without these surveys we would have no data, but limitations remain particularly in detecting deaths on the first day of life. Comparable reliable neonatal cause of death data through vital registration are available for less than 5% of the world's neonatal deaths, necessitating modelled estimates for the majority of the world. Improving the quantity, quality and frequency of data for numbers and causes of neonatal deaths is essential to effectively guide the increasing investments to reduce these deaths. Advancing the data requires general investment in information systems and specific improvements of tools and methods for both household surveys and verbal autopsy, particularly the use of consistent case definitions and hierarchical attribution of cause of death. An important paradigm shift is from historical categories for cause of death ('perinatal causes') to programmatic categories which are consistent with the International Classification of Diseases. If neonatal deaths remain uncounted, they cannot count in policy and in programmes.

On risks and benefits of iron supplementation recommendations for iron intake revisited

Iron is an essential trace element with a high prevalence of deficiency in infants and in women of reproductive age from developing countries. Iron deficiency is frequently associated with anaemia and, thus, with reduced working capacity and impaired intellectual development. Moreover, the risk for premature delivery, stillbirth and impaired host-defence is increased in iron deficiency. Iron-absorption and -distribution are homeostatically regulated to reduce the risk for deficiency and overload. These mechanisms interact, in part, with the mechanisms of oxidative stress and inflammation and with iron availability to pathogens. In the plasma, fractions of iron may not be bound to transferrin and are hypothesised to participate in atherogenesis. Repleted iron stores and preceding high iron intakes reduce intestinal iron absorption which, however, offers no reliable protection against oral iron overload. Recommendations for dietary iron intake at different life stages are given by the US Food and Nutrition Board (FNB), by FAO/WHO and by the EU Scientific Committee, among others. They are based, on estimates for iron-losses, iron-bioavailability from the diet, and iron-requirements for metabolism and growth. Differences in choice and interpretation of these estimates lead to different recommendations by the different panels which are discussed in detail. Assessment of iron-related risks is based on reports of adverse health effects which were used in the attempts to derive an upper safe level for dietary iron intake. Iron-related harm can be due to direct intestinal damage, to oxidative stress, or to stimulated growth of pathogens. Unfortunately, it is problematic to derive a reproducible cause-effect and dose-response relationship for adverse health effects that suggest a relationship to iron-intake, be they based on mechanistic or epidemiological observations. Corresponding data and interpretations are discussed for the intestinal lumen, the vascular system and for the intracellular and interstitial space, considering interference of the mechanisms of iron homoeostasis as a likely explanation for differences in epidemiological observations.

Assessment of risk factors for stillbirth among pregnant women in Jamaica

A case - control study was conducted to assess the risk factors of stillbirth among pregnant women in Jamaica. A total of 314 women participated (160 with stillborn babies and 154 with live-born babies). A questionnaire designed to collect information on sociodemographic characteristics, antenatal care, medical and sexually transmitted disease (STD) history, method of delivery and infant birth and health status was administered to each woman. Medical records were reviewed to verify medical history. Six variables were found to be significant predictors of stillbirth by multivariate logistic regression. Low birth weight (OR = 4.3, CI = 2.4 - 7.7), complications during pregnancy or delivery (OR = .19, CI = 0.09 - 0.41), method of delivery (caesarean section; OR = 7.2, CI = 1.6 - 33.2), number of living children (OR = 0.54, CI = 0.40 - 0.73), number of antenatal visits (less than three; OR = 2.0, CI = 1.3 - 3.1), and presence of unfavourable and /or adverse fetal outcome (OR = 4.0, CI = 1.8 - 9.2) were found to be associated with stillbirth. These findings have important implications in establishing policies for prenatal care in Jamaica.

Can clinical risk factors for late stillbirth in West Africa be detected during antenatal care or only during labour?

BACKGROUND

Recent studies have shown that the most important risk factors for perinatal mortality in developing countries are not detectable during antenatal care but can be observed only shortly before or during labour. Although 60% of perinatal deaths in these countries are stillbirths, few epidemiological studies focus on them. We tested the hypothesis that the risk factors for late stillbirth in West Africa are detectable principally shortly before or during labour.

METHODS

Data came from a prospective population-based study (the MOMA survey) that collected information about 20 326 pregnant women in seven areas, primarily urban, in West Africa.

RESULTS

There were 19 870 singleton births. The stillbirth rate was 25.9 per 1000 total births (95% CI: 23.7-28.1). In the crude analysis, after adjustment and consideration of prevalence, the principal risk factors for late stillbirth were: late antenatal or intrapartum vaginal bleeding, intrapartum hypertension, dystocia, and infection. Other risk factors were: maternal height (<150 cm), maternal age (>35 years), previous stillbirths, hypertension at the 8-month antenatal visit and number of antenatal visits (<2).

CONCLUSIONS

The principal risk factors for late stillbirth observed in our study could be detected only in the late antenatal and intrapartum period. These results highlight the potential benefits of partograph use. They need to be confirmed by studies incorporating continuous intrapartum fetal monitoring.

Access to care and maternal mortality in Jamaican hospitals: 1993-1995

BACKGROUND

As part of the reproductive health quality assurance programme, the Ministry of Health sought to review maternal deaths in public hospitals. These hospitals attend 95% of institutional births and 82% of all births.

METHODS

Deaths among females 10-50 years in public hospitals during 1993-1995 were reviewed to identify pregnancy-related deaths. Cause of death and access to care were compared with previous studies (1981-1983 and 1986-1987 [12 months]).

RESULTS

The maternal mortality ratio of 106.2 per 100 000 live births, was no different than the 119.7 observed in 1986-1987 and 118.6 for 1981-1983. The leading causes of death remained pre-eclampsia/eclampsia and haemorrhage. The only significant cause-specific decline occurred among deaths due to ruptured ectopic pregnancy (P = 0.012). While in 1986-1987 access to care was associated with risk of death from gestational hypertension (P = 0.02), these differences are no longer significant. Differences persist, however, for haemorrhage and all other causes, which were less likely to occur at the more skilled institutions. The region with the least obstetricians had the highest mortality ratio but the one with the most did not have the lowest ratio, indicating that quality is more important than quantity.

CONCLUSIONS

Regional differences indicate the capacity to reduce maternal mortality by at least 50% with re-allocation of skilled personnel and improved quality. All hospitals must be able to manage haemorrhage cases as patients are unlikely to survive referral.

Anemia and iron deficiency: effects on pregnancy outcome

This article reviews current knowledge of the effects of maternal anemia and iron deficiency on pregnancy outcome. A considerable amount of information remains to be learned about the benefits of maternal iron supplementation on the health and iron status of the mother and her child during pregnancy and postpartum. Current knowledge indicates that iron deficiency anemia in pregnancy is a risk factor for preterm delivery and subsequent low birth weight, and possibly for inferior neonatal health. Data are inadequate to determine the extent to which maternal anemia might contribute to maternal mortality. Even for women who enter pregnancy with reasonable iron stores, iron supplements improve iron status during pregnancy and for a considerable length of time postpartum, thus providing some protection against iron deficiency in the subsequent pregnancy. Mounting evidence indicates that maternal iron deficiency in pregnancy reduces fetal iron stores, perhaps well into the first year of life. This deserves further exploration because of the tendency of infants to develop iron deficiency anemia and because of the documented adverse consequences of this condition on infant development. The weight of evidence supports the advisability of routine iron supplementation during pregnancy.

A randomised trial of low dose aspirin for primiparae in pregnancy. The Jamaica Low Dose Aspirin Study Group

OBJECTIVE

To investigate whether low dose aspirin medication given to primiparous women provides benefit in preventing pre-eclampsia or intrauterine growth retardation.

DESIGN

Randomised double-blind controlled trial of low dose aspirin and placebo in pregnancy.

POPULATION

Residents of the parishes of Kingston and St Andrew, Jamaica; 6275 primiparae enrolled between 12 and 32 weeks of gestation.

MAIN OUTCOME MEASURES

Hypertensive disorders of pregnancy (including pre-eclampsia and eclampsia), preterm delivery, and low birthweight. In addition, to assess whether enrollment early, rather than late had more beneficial effect. Possible adverse effects on the woman and her infant were monitored.

RESULTS

Of enrolled primiparae, 97% were followed throughout pregnancy. There were no differences between those on aspirin and those on placebo in the development of hypertensive disorders (e.g. for a rise in diastolic pressure of 25 mmHg the odds ratio [OR] was 1.02 [95% CI 0.86-1.21]; for proteinuric pre-eclampsia OR 1.15 [95% CI 0.92-1.44]; eclampsia OR 0.82 [95% CI 0.44-1.53]); except for oedema which was significantly less prevalent in those on aspirin (OR 0.85 [95% CI 0.75-0.96]). Women on aspirin were no significantly less likely to deliver preterm (OR 0.93 [95% CI 0.79-1.09]) or have a larger fetus (mean birthweight difference 18 g [95% CI -9 to 45]). They were, however, significantly more likely to suffer from bleeding disorders antenatally, intrapartum and postpartum; for postpartum haemorrhage OR 1.40 (95% CI 1.13-1.73).

CONCLUSIONS

This trial shows that low dose aspirin has no consistent beneficial effect in primiparae.

Assessment of risk of perinatal death in Jamaica

Data from the Jamaican Perinatal Mortality Survey had been used to create a statistical model using logistic regression. From this a simple additive scoring system to predict perinatal death was devised and tested on the 2 cohort months of the study. The score had a theoretical range of 0-28 points, with the higher the score, the greater the likelihood of a perinatal death. For a cut-point of 7, sensitivity was 43% and specificity 84%. A cut-point of 8 resulted in 27% sensitivity and 94% specificity. Higher cut-points resulted in much reduced sensitivity but enhanced specificity (e.g. cut-point 10: 11% sensitivity, 99% specificity). However, it is likely that these estimates are optimistically high, and to achieve unbiased estimates of sensitivity and specificity the score needs to be tested on a sample of the population from which it was not derived before implementation takes place. Meanwhile, the cut-off level for implementation will depend on appropriate resources available.