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

2. Outline Introduction Study Purpose Methodology Results Implications 1

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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. Results No. of records - 606n Percentage Type of deliveries SVD419 69 C/S165 27.2 VE/ Breech21 3.5 Term Gestation534 89 Skilled attendant581 95.9 9

11. Results- Mothers’ characteristics n Percentage Age group 14- 18115 19 19- 35437 72.3 36- 4653 8.8 Parity 1211 34.8 2- 4310 51.2 ≥ 585 14 10

12. Results- Mothers’ characteristics ctd… n Percentage No. of antenatal visits 134 5.7 2119 19.8 3-4389 64.8 ≥ 558 9.7 11

13. Results - Frequency of perinatal deaths n Percentage Total Deliveries685 Number of fresh still births 18 2.6 Number of macerated still births 7 1 Number of early neonatal deaths 16 2.4 Perinatal deaths41 5.9 12

14. 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

15. Distribution of perinatal deaths 14

16. Causes of early neonatal deaths Percentage Birth asphyxia 75 Severe prematurity (28- 30 weeks) 12.5 Severe prematurity & sepsis 12.5 15

17. Results- univariate analysis (Pregnancy) CharacteristicPerinatal deaths No Yes P-value † No. of antenatal visits n % <0.001 124 70.610 29.4 2110 929 8 3197 976 3 4177 959 5 ≥551 887 12 16 Maternal age, parity, HIV, syphilis, preeclampsia, anemia, malaria and APH had no effect on perinatal deaths (p >0.05).

18. Results- univariate analysis (Labor/Delivery) CharacteristicPerinatal deaths No Yes P-value † Gestationn % <0.001 ≤3110 539 47 32-36140 9311 7 ≥37405 9521 5 Labor &Delivery complication<0.001 No351 9710 3 Yes206 8827 12 Preterm labour0.029 No165 9019 10 Yes11 695 31 17

19. Results- univariate analysis (Labor/Delivery) ctd… CharacteristicPerinatal deaths No Yes P-value † Presentationn % <0.001 Cephalic533 9433 6 Breech23 796 21 Compound4 672 33 Prolonged 2 nd stage of labor<0.001 No525 9530 5 Yes39 7811 22 18

20. Results- univariate analysis (Labor/Delivery) ctd… CharacteristicPerinatal deaths No Yes P-value † Delivery typen % 0.012 SVD396 9523 5 C/S152 9213 7.8 VE/Breech/ Breech extraction 16 765 24 19 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).

21. Results- univariate analysis (Postpartum) CharacteristicPerinatal deaths No Yes P-value † Asphyxian % <0.001 No502 995 1 Yes63 8511 15 Apgar score<0.001 1-37 546 46 4-660 916 9 7-10498 99.24 0.8 Preterm<0.001 No514 9620 4 Yes50 7616 24 20

22. Results- univariate analysis (Postpartum) ctd.. CharacteristicPerinatal deaths No Yes P-value † Birth weight n % <0.001 700g-1499g7 3911 61 1500g-2499g93 919 ≥2500g463 9620 4 Sepsis0.009 No444 99.62 0.4 Yes17 89.52 10.5 21 Meconium aspiration and hypothermia were not associated with perinatal deaths (p >0.05).

23. 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

24. 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