1. Perinatal Mortality in Rift Valley Provincial General Hospital between May and October 2014 Mark Maugo FELTP University of Nairobi MBChB Level V

2. 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

3. “Perinatal mortality is a key indicator of the health status and socio-economic development of a community” World Health Organization, 1996

4. Why perinatal mortality?

5. 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

6. 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

7. 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)

8. 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

9. Results

10. 4683 total births during that period Perinatal Mortality Rate of 47.4 per 1000 total births 222 perinatal deaths 88 stillbirths (40.1%) 134 early neonatal deaths (59.9%) 241 Records Collected 222 records analyzed 19 records did not meet the exclusion criteria Stillbirths in developing countries still invisible to existing perinatal surveillance

11. Characteristics of perinatal deaths

12. Causes of early neonatal death

13. Cumulative probability of causes of early neonatal death by age of death in RVPGH between May 2014-Oct 2014

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

15. Low birth weight and prematurity 151 (67.7%) of the perinatal deaths weighed less than 2500g Mean gestational age was 34.5 weeks

16. 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

17. 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

18. 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

19. Three Delay Model

20. Three levels of delay identified in the perinatal deaths that occurred in RVPGH between May and October 2014

21. Limitations Incomplete records Possible reporting bias

22. 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.

23. 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

24. Acknowledgements 1)Field Epidemiology and Lab Training Program(FELTP) 2)Centers for Disease Control and Prevention 3)The University of Nairobi, Faculty of Medicine 4)Rift Valley Provincial General Hospital

25. Thank You