Factors associated with perinatal deaths in women delivering in a health facility in Malawi Lily C. Kumbani, Johanne Sundby and Jon Øyvind Odland

Outline Introduction Study Purpose Methodology Results Implications 1

Introduction Newborn deaths account for 40% of under- five mortality (MDG- 4). Reducing early neonatal mortality is necessary to achieve MDG- 4. 2

Introduction ctd… Two-thirds of child deaths occur in the first month of life. Of these, more than two- thirds die in their first week. Among those in the first week, two-thirds die in the first 24 hours of life. Unless neonatal mortality is greatly reduced it is not possible to achieve millennium development goal 4. 3

Introduction ctd… In Malawi, an increase in perinatal mortality estimated at 40/1000 (MDHS 2010) Few studies done. These data are essential to effectively plan how to reduce perinatal mortality. 4

Objectives To establish an estimate of perinatal mortality at Chiradzulu District Hospital. To identify associated risk factors, and to determine causes of perinatal deaths. 5

Methodology Design: A cross sectional prospective review of records. Setting: Chiradzulu district hospital, labor ward and postnatal ward. Inclusion criteria: Records of mothers who received antenatal care at any health facility but delivered at the district hospital from 28 weeks to term. 6

Methodology ctd… Data collection: A data record form: was used to collect maternal and neonatal information Data analysis Stata version 11.0 was used Univariate analysis was computed to determine the association between outcome (perinatal death) and independent variables. 7

Methodology ctd… Ethical consideration: Study approval - Norway Regional Committee for Medical Research Ethics & College of Medicine Research and Ethics Committee, Malawi. Written permission from the District Health Officer - Chiradzulu District Hospital 8

Results No. of records - 606n Percentage Type of deliveries SVD C/S VE/ Breech Term Gestation Skilled attendant

Results- Mothers’ characteristics n Percentage Age group Parity ≥

Results- Mothers’ characteristics ctd… n Percentage No. of antenatal visits ≥

Results - Frequency of perinatal deaths n Percentage Total Deliveries685 Number of fresh still births Number of macerated still births 7 1 Number of early neonatal deaths Perinatal deaths

Results - Frequency of perinatal deaths ctd… Rate Perinatal mortality rate59.9/ 1000 births Still birth rate36/ 1000 births Early neonatal death rate 24/1000 live births 13

Distribution of perinatal deaths 14

Causes of early neonatal deaths Percentage Birth asphyxia 75 Severe prematurity ( weeks) 12.5 Severe prematurity & sepsis

Results- univariate analysis (Pregnancy) CharacteristicPerinatal deaths No Yes P-value † No. of antenatal visits n % < ≥ Maternal age, parity, HIV, syphilis, preeclampsia, anemia, malaria and APH had no effect on perinatal deaths (p >0.05).

Results- univariate analysis (Labor/Delivery) CharacteristicPerinatal deaths No Yes P-value † Gestationn % <0.001 ≤ ≥ Labor &Delivery complication<0.001 No Yes Preterm labour0.029 No Yes

Results- univariate analysis (Labor/Delivery) ctd… CharacteristicPerinatal deaths No Yes P-value † Presentationn % <0.001 Cephalic Breech Compound Prolonged 2 nd stage of labor<0.001 No Yes

Results- univariate analysis (Labor/Delivery) ctd… CharacteristicPerinatal deaths No Yes P-value † Delivery typen % SVD C/S VE/Breech/ Breech extraction Anemia, obstetric complications (preeclampsia, eclampsia, rupture of membranes > 24 hours, fetal distress, CPD, obstructed labor), and skilled attendant were not associated with perinatal deaths (p >0.05).

Results- univariate analysis (Postpartum) CharacteristicPerinatal deaths No Yes P-value † Asphyxian % <0.001 No Yes Apgar score< Preterm<0.001 No Yes

Results- univariate analysis (Postpartum) ctd.. CharacteristicPerinatal deaths No Yes P-value † Birth weight n % < g-1499g g-2499g ≥2500g Sepsis0.009 No Yes Meconium aspiration and hypothermia were not associated with perinatal deaths (p >0.05).

Implications Reinforce and improve health workers’ abilities to properly monitor women in labor at all levels of care for early identification and management of complications. Encourage women to start antenatal care early for them to adhere to the four recommended antenatal visits. Improve health workers ability in basic resuscitation, as well as care of low birth weight babies. 22

Implications ctd… Referral of women with very preterm labor (28 to 32 weeks) to deliver in a facility with neonatal intensive care. Pregnant women and communities should have sufficient information on obstetric complications to seek health care in time. 23