Cesarean Sections in Non-Teaching Hospitals

A review of 253 Cesarean sections in two non-teaching general hospitals was carried out to compare the results in these hospitals with the standards set by large teaching institutions. The results of the study were gratifying in that the incidence of Cesarean section was well within the accepted rate of 5% to 6% of deliveries. As well, the perinatal and maternal mortality and morbidity rates were comparatively low. It was apparent, however, that in these institutions there was a need for more accurate and detailed records and that there should be a reduction in the number of classical Cesarean operations. This study also revealed that there was a tendency to use blood transfusions and antibiotics without clear-cut indications.     

Measures of performance in Scottish maternity hospitals.

OBJECTIVE--To develop measures of hospital performance over time with particular reference to maternal and neonatal care by controlling for case mix. DESIGN--Analysis of computerised records of births. SETTING--Scotland, 1980-7. SUBJECTS--Over half a million singleton live births and stillbirths. MAIN OUTCOME MEASURES--Numbers of perinatal deaths and caesarean sections. RESULTS--Scottish maternity hospitals perform more or less equally with regard to perinatal mortality. When caesarean sections are considered, there is evidence that hospitals differ in their treatment of different groups of women; in two examples one hospital had an increased rate among women of parity 2 or more and another had a reduced rate of repeat caesarean section. CONCLUSIONS--Developing measures of performance over time by controlling for case mix is a valid system for monitoring hospital outcomes and activity, and allows comparison either between hospitals or with data for all Scottish maternity hospitals. Hospital profiles permit identification of differences for particular patient groups after allowance is made for other case mix variables.     

Medical technicians; the present need and training in California

A maternal welfare committee was founded in 1947 by representatives of nine hospitals in San Diego County, with the purpose of inquiring into all deaths involving maternity in order to reduce maternal mortality. At open meetings cases of such death are reviewed and a vote is taken on whether the death was preventable. Deaths of newborn children are also investigated for preventable factors. From 1947 to 1952 the maternal mortality rate has declined among residents of the county from 7.3 per the thousand live births to 2.7. It is believed that the emphasis placed on high standards of prenatal and postpartum care by the committee's observations has greatly aided in securing this improvement.     

MEDICAL TECHNICIANS—The Present Need and Training in California

A maternal welfare committee was founded in 1947 by representatives of nine hospitals in San Diego County, with the purpose of inquiring into all deaths involving maternity in order to reduce maternal mortality. At open meetings cases of such death are reviewed and a vote is taken on whether the death was preventable. Deaths of newborn children are also investigated for preventable factors.From 1947 to 1952 the maternal mortality rate has declined among residents of the county from 7.3 per the thousand live births to 2.7. It is believed that the emphasis placed on high standards of prenatal and postpartum care by the committee''s observations has greatly aided in securing this improvement.     

Prevalence and determinants of caesarean section in Jamaica.

The prevalence and determinants of primary caesarean section in Jamaica were estimated from a survey of women aged 14-49 years. Among 2328 women reporting 2395 live hospital births during the period January 1984 to May 1989, the prevalence of caesarean section was 4.1%. Repeat caesarean sections accounted for 1.3% of the hospital births during that period. Of the medical complications studied, prolonged labour and/or cephalopelvic disproportion carried the highest risks of primary caesarean section, followed by breech presentation, maternal diabetes, a high birth-weight baby, maternal hypertension, and a low birth-weight baby. The risk of primary caesarean section increased with maternal age, decreased with parity, was higher for urban than for rural residents, and was higher for births in private versus government hospitals.     

Causes of Early Childhood Deaths in Urban Dhaka,Bangladesh

Data on causes of early childhood death from low-income urban areas are limited. The nationally representative Bangladesh Demographic and Health Survey 2007 estimates 65 children died per 1,000 live births. We investigated rates and causes of under-five deaths in an urban community near two large pediatric hospitals in Dhaka, Bangladesh and evaluated the impact of different recall periods. We conducted a survey in 2006 for 6971 households and a follow up survey in 2007 among eligible remaining households or replacement households. The initial survey collected information for all children under five years old who died in the previous year; the follow up survey on child deaths in the preceding five years. We compared mortality rates based on 1-year recall to the 4 years preceding the most recent 1 year. The initial survey identified 58 deaths among children <5 years in the preceding year. The follow up survey identified a mean 53 deaths per year in the preceding five years (SD±7.3). Under-five mortality rate was 34 and neonatal mortality was 15 per thousand live births during 2006–2007. The leading cause of under-five death was respiratory infections (22%). The mortality rates among children under 4 years old for the two time periods (most recent 1-year recall and the 4 years preceding the most recent 1 year) were similar (36 versus 32). The child mortality in urban Dhaka was substantially lower than the national rate. Mortality rates were not affected by recall periods between 1 and 5 years.     

Maternal Mortality in India: Causes and Healthcare Service Use Based on a Nationally Representative Survey

Background

Data on cause-specific mortality, skilled birth attendance, and emergency obstetric care access are essential to plan maternity services. We present the distribution of India''s 2001–2003 maternal mortality by cause and uptake of emergency obstetric care, in poorer and richer states.

Methods and Findings

The Registrar General of India surveyed all deaths occurring in 2001–2003 in 1.1 million nationally representative homes. Field staff interviewed household members about events that preceded the death. Two physicians independently assigned a cause of death. Narratives for all maternal deaths were coded for variables on healthcare uptake. Distribution of number of maternal deaths, cause-specific mortality and uptake of healthcare indicators were compared for poorer and richer states. There were 10 041 all-cause deaths in women age 15–49 years, of which 1096 (11.1%) were maternal deaths. Based on 2004–2006 SRS national MMR estimates of 254 deaths per 100 000 live births, we estimated rural areas of poorer states had the highest MMR (397, 95%CI 385–410) compared to the lowest MMR in urban areas of richer states (115, 95%CI 85–146). We estimated 69 400 maternal deaths in India in 2005. Three-quarters of maternal deaths were clustered in rural areas of poorer states, although these regions have only half the estimated live births in India. Most maternal deaths were attributed to direct obstetric causes (82%). There was no difference in the major causes of maternal deaths between poorer and richer states. Two-thirds of women died seeking some form of healthcare, most seeking care in a critical medical condition. Rural areas of poorer states had proportionately lower access and utilization to healthcare services than the urban areas; however this rural-urban difference was not seen in richer states.

Conclusions

Maternal mortality and poor access to healthcare is disproportionately higher in rural populations of the poorer states of India.     

Perinatal mortality and adverse pregnancy outcomes in a low-income rural population of women who smoke

We describe adverse pregnancy outcomes, including congenital anomalies, fetal, neonatal, and infant mortality among a Missouri population of low-income, rural mothers who participated in two randomized smoking cessation trials. In the Baby BEEP (BB) trial, 695 rural women were recruited from 21 WIC clinics with 650 women's pregnancy outcomes known (93.5% retention rate). Following the BB trial, 298 women who had a live infant after November 2004 were recruited again into and completed the Baby Beep for Kids (BBK) trial. Simple statistics describing the population and perinatal and postneonatal mortality rates were calculated. Of the adverse pregnancy outcomes (n = 79), 29% were spontaneous abortions of less than 20 weeks' gestation, 23% were premature births, and 49% were identified birth defects. The perinatal mortality rate was 15.9 per 1000 births (BB study) compared with 8.6 per 1000 births (state of Missouri) and 8.5 per 1000 births (United States). The postneonatal infant mortality rate was 13.4 per 1000 live births (BBK) compared with 2.1 per 1000 live births (United States). The health disparity in this population of impoverished, rural, pregnant women who smoke, particularly in regard to perinatal and infant deaths, warrants attention.     

Perinatal mortality and adverse pregnancy outcomes in a low‐income rural population of women who smoke

We describe adverse pregnancy outcomes, including congenital anomalies, fetal, neonatal, and infant mortality among a Missouri population of low‐income, rural mothers who participated in two randomized smoking cessation trials. In the Baby BEEP (BB) trial, 695 rural women were recruited from 21 WIC clinics with 650 women's pregnancy outcomes known (93.5% retention rate). Following the BB trial, 298 women who had a live infant after November 2004 were recruited again into and completed the Baby Beep for Kids (BBK) trial. Simple statistics describing the population and perinatal and postneonatal mortality rates were calculated. Of the adverse pregnancy outcomes (n = 79), 29% were spontaneous abortions of less than 20 weeks' gestation, 23% were premature births, and 49% were identified birth defects. The perinatal mortality rate was 15.9 per 1000 births (BB study) compared with 8.6 per 1000 births (state of Missouri) and 8.5 per 1000 births (United States). The postneonatal infant mortality rate was 13.4 per 1000 live births (BBK) compared with 2.1 per 1000 live births (United States). The health disparity in this population of impoverished, rural, pregnant women who smoke, particularly in regard to perinatal and infant deaths, warrants attention. Birth Defects Research (Part A), 2012. © 2012 Wiley Periodicals, Inc.     

A study of infant mortality and causes of death in a rural north-east Brazilian community

In 1984 a prospective study of 1645 women and 1677 births in a rural community in north-eastern Brazil showed the infant mortality rate to be 65 per 1000 live births. Neonatal, post-neonatal and infant mortality are analysed to determine the most important risk factors for each period. Post-neonatal survival depends largely on factors relating to child care, while neonatal deaths are more likely to be associated with biological factors. The principal cause of death, diarrhoeal disease, was responsible for a third of the deaths.     

Perinatal mortality rates in isolated general practitioner maternity units.

OBJECTIVE--To determine the perinatal mortality rate among normally formed, singleton babies with birth weights greater than or equal to 2500 g in Bath health district based on the intended place of delivery at the time of onset of labour or at the time of diagnosis of intrauterine death. DESIGN--The numbers of live births and stillbirths were collected monthly returns from the maternity units concerned. Deaths of infants aged less than or equal to 1 week were collected in the same returns. The intended place of delivery was confirmed at the monthly perinatal mortality meeting, during which maternal and fetal factors were discussed. SETTING--A rural health district of 400,000 population where one third of all deliveries occurred in seven isolated general practitioner maternity units, 8% in the integrated general practitioner unit, and the remainder in the consultant unit. SUBJECTS--All babies of women whose deliveries were booked in the district before the onset of labour or the diagnosis of intrauterine death, excluding twins, babies with lethal congenital malformations, and those less than 2500 g. MAIN OUTCOME MEASURES--Outcome of all deliveries and parity of mothers. RESULTS--14,415 Deliveries were analysed. The perinatal mortality rate was 2.8/1000 births in the consultant unit (7950 deliveries), 4.8 in the isolated general practitioner units (5237 deliveries), and zero in the integrated general practitioner unit (1228 deliveries). Perinatal deaths attributable to asphyxia were more common in the isolated general practitioner units (1.5 per 1000) than the consultant unit (0.6 per 1000). The perinatal mortality rate among babies born to nulliparous women was 3.2/1000 births in the consultant unit and 5.7 in the isolated general practitioner units; for those born to multigravid women it was 2.4 and 4.2 respectively. CONCLUSIONS--The outcome of delivery was not influenced by parity. Both antenatal and intrapartum care were responsible for the higher perinatal mortality rate in the isolated general practitioner units. The integrated unit, which shared midwifery staff with the consultant unit, seemed to work well. Analysis by intended place of delivery at the time of onset of labour or diagnosis of intrauterine death suggested that the care given in isolated units needs to be improved, perhaps by better training of general practitioners and consultant supervision of antenatal care.     

Perinatal deaths: analysis by clinical cause to assess value of induction of labour.

Over the 10 years 1966-75 the rate of induction of labour in the Glasgow Royal Maternity Hospital has increased from 16-3% of all births. During the same period perinatal mortality fell from 33 to 22 per 1000, mainly because of significantly fewer deaths due to antepartum haemorrhage; trauma; maternal diseases; and unknown causes in mature babies. The reduction in the number of deaths of unknown causes in mature fetuses was achieved by preventing deaths occurring after 40 weeks and was recorded in all age and parity groups. The results suggested that increased use of induction of labour has contributed to the improved perinatal mortality rate.     

Maternal mortality in British Columbia in 1971-86.

We reviewed the 56 maternal deaths in British Columbia in 1971-78 and 1979-86 identified through the provincial Ministry of Health and compared the findings with data for the two preceding 8-year periods. The maternal death rate, defined as the number of deaths directly or indirectly related to pregnancy or delivery per 100,000 live births, decreased from 42 in 1955-62 to 5 in 1979-86. In the same interval the number of direct obstetric deaths decreased from 100 to 10 and the number of indirect deaths from 29 to 8. The number of deaths due to abortion decreased from 32 to 1. There was no change in the number of deaths among North American Indians. There was also no change in the number of deaths due to hypertension, most of which were avoidable; these findings have stimulated intensive teaching efforts to increase recognition and improve management of the problem. Review of maternal deaths can help identify deficiencies in the quality of care and can direct measures aimed at further reducing the maternal death rate.     

CESAREAN SECTION EXPERIENCE AT THE UNIVERSITY OF CALIFORNIA HOSPITAL

A review of the 746 cesarean sections performed at the University of California Hospital from 1907 through 1948 shows an overall cesarean section incidence of 3.91 per cent. The maternal mortality rate associated with these cesarean sections has been 1.61 per cent. There has been a steady decline in mortality over the 40-year period and there have been no deaths from cesarean section in the last ten years. The over-all incidence of morbidity associated with cesarean section has been 40.5 per cent and again there has been a significant improvement in recent years. The fetal mortality associated with cesarean section has been 6.1 per cent. In view of recent experience, standards based on figures collected 20 years ago are no longer tenable.     

Maternal Mortality in Rural South Ethiopia: Outcomes of Community-Based Birth Registration by Health Extension Workers

Introduction

Rural communities in low-income countries lack vital registrations to track birth outcomes. We aimed to examine the feasibility of community-based birth registration and measure maternal mortality ratio (MMR) in rural south Ethiopia.

Methods

In 2010, health extension workers (HEWs) registered births and maternal deaths among 421,639 people in three districts (Derashe, Bonke, and Arba Minch Zuria). One nurse-supervisor per district provided administrative and technical support to HEWs. The primary outcomes were the feasibility of registration of a high proportion of births and measuring MMR. The secondary outcome was the proportion of skilled birth attendance. We validated the completeness of the registry and the MMR by conducting a house-to-house survey in 15 randomly selected villages in Bonke.

Results

We registered 10,987 births (81·4% of expected 13,492 births) with annual crude birth rate of 32 per 1,000 population. The validation study showed that, of 2,401 births occurred in the surveyed households within eight months of the initiation of the registry, 71·6% (1,718) were registered with similar MMRs (474 vs. 439) between the registered and unregistered births. Overall, we recorded 53 maternal deaths; MMR was 489 per 100,000 live births and 83% (44 of 53 maternal deaths) occurred at home. Ninety percent (9,863 births) were at home, 4% (430) at health posts, 2·5% (282) at health centres, and 3·5% (412) in hospitals. MMR increased if: the male partners were illiterate (609 vs. 346; p= 0·051) and the villages had no road access (946 vs. 410; p= 0·039). The validation helped to increase the registration coverage by 10% through feedback discussions.

Conclusion

It is possible to obtain a high-coverage birth registration and measure MMR in rural communities where a functional system of community health workers exists. The MMR was high in rural south Ethiopia and most births and maternal deaths occurred at home.     

Outcomes of planned home births with certified professional midwives: large prospective study in North America

Objective To evaluate the safety of home births in North America involving direct entry midwives, in jurisdictions where the practice is not well integrated into the healthcare system.Design Prospective cohort study.Setting All home births involving certified professional midwives across the United States (98% of cohort) and Canada, 2000.Participants All 5418 women expecting to deliver in 2000 supported by midwives with a common certification and who planned to deliver at home when labour began.Main outcome measures Intrapartum and neonatal mortality, perinatal transfer to hospital care, medical intervention during labour, breast feeding, and maternal satisfaction.Results 655 (12.1%) women who intended to deliver at home when labour began were transferred to hospital. Medical intervention rates included epidural (4.7%), episiotomy (2.1%), forceps (1.0%), vacuum extraction (0.6%), and caesarean section (3.7%); these rates were substantially lower than for low risk US women having hospital births. The intrapartum and neonatal mortality among women considered at low risk at start of labour, excluding deaths concerning life threatening congenital anomalies, was 1.7 deaths per 1000 planned home births, similar to risks in other studies of low risk home and hospital births in North America. No mothers died. No discrepancies were found for perinatal outcomes independently validated.Conclusions Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.     

Maternal and Neonatal Mortality in South-West Ethiopia: Estimates and Socio-Economic Inequality

Introduction

Ethiopia has achieved the fourth Millennium Development Goal by reducing under 5 mortality. Nevertheless, there are challenges in reducing maternal and neonatal mortality. The aim of this study was to estimate maternal and neonatal mortality and the socio-economic inequalities of these mortalities in rural south-west Ethiopia.

Methods

We visited and enumerated all households but collected data from those that reported pregnancy and birth outcomes in the last five years in 15 of the 30 rural kebeles in Bonke woreda, Gamo Gofa, south-west Ethiopia. The primary outcomes were maternal and neonatal mortality and a secondary outcome was the rate of institutional delivery.

Results

We found 11,762 births in 6572 households; 11,536 live and 226 stillbirths. There were 49 maternal deaths; yielding a maternal mortality ratio of 425 per 100,000 live births (95% CI:318–556). The poorest households had greater MMR compared to richest (550 vs 239 per 100,000 live births). However, the socio-economic factors examined did not have statistically significant association with maternal mortality. There were 308 neonatal deaths; resulting in a neonatal mortality ratio of 27 per 1000 live births (95% CI: 24–30). Neonatal mortality was greater in households in the poorest quartile compared to the richest; adjusted OR (AOR): 2.62 (95% CI: 1.65–4.15), headed by illiterates compared to better educated; AOR: 3.54 (95% CI: 1.11–11.30), far from road (≥6 km) compared to within 5 km; AOR: 2.40 (95% CI: 1.56–3.69), that had three or more births in five years compared to two or less; AOR: 3.22 (95% CI: 2.45–4.22). Households with maternal mortality had an increased risk of stillbirths; OR: 11.6 (95% CI: 6.00–22.7), and neonatal deaths; OR: 7.2 (95% CI: 3.6–14.3). Institutional delivery was only 3.7%.

Conclusion

High mortality with socio-economic inequality and low institutional delivery highlight the importance of strengthening obstetric interventions in rural south-west Ethiopia.     

Maternal Mortality in Henan Province,China: Changes between 1996 and 2009

Background

Maternal deaths occur mostly in developing countries and the majority of them are preventable. This study analyzes changes in maternal mortality and related causes in Henan Province, China, between 1996 and 2009, in an attempt to provide a reliable basis for introducing effective interventions to reduce the maternal mortality ratio (MMR), part of the fifth Millennium Development Goal.

Methods and Findings

This population-based maternal mortality survey in Henan Province was carried out from 1996 to 2009. Basic information was obtained from the health care network for women and children and the vital statistics system, from specially trained monitoring personnel in 25 selected monitoring sites and by household survey in each case of maternal death. This data was subsequently reported to the Henan Provincial Maternal and Child Healthcare Hospital. The total MMR in Henan Province declined by 78.4%, from 80.1 per 100 000 live births in 1996 to 17.3 per 100 000 live births in 2009. The decline was more pronounced in rural than in urban areas. The most common causes of maternal death during this period were obstetric hemorrhage (43.8%), pregnancy-induced hypertension (15.8%), amniotic fluid embolism (13.9%) and heart disease (8.0%). The MMR was higher in rural areas with lower income, less education and poorer health care.

Conclusion

There was a remarkable decrease in the MMR in Henan Province between 1996 and 2009 mainly in the rural areas and MMR due to direct obstetric causes such as obstetric hemorrhage. This study indicates that improving the health care network for women, training of obstetric staff at basic-level units, promoting maternal education, and increasing household income are important interventional strategies to reduce the MMR further.     

Disparities and Trends in Birth Outcomes,Perinatal and Infant Mortality in Aboriginal vs. Non-Aboriginal Populations: A Population-Based Study in Quebec,Canada 1996–2010

Background

Aboriginal populations are at substantially higher risks of adverse birth outcomes, perinatal and infant mortality than their non-Aboriginal counterparts even in developed countries including Australia, U.S. and Canada. There is a lack of data on recent trends in Canada.

Methods

We conducted a population-based retrospective cohort study (n = 254,410) using the linked vital events registry databases for singleton births in Quebec 1996–2010. Aboriginal (First Nations, Inuit) births were identified by mother tongue, place of residence and Indian Registration System membership. Outcomes included preterm birth, small-for-gestational-age, large-for-gestational-age, low birth weight, high birth weight, stillbirth, neonatal death, postneonatal death, perinatal death and infant death.

Results

Perinatal and infant mortality rates were 1.47 and 1.80 times higher in First Nations (10.1 and 7.3 per 1000, respectively), and 2.37 and 4.46 times higher in Inuit (16.3 and 18.1 per 1000, respectively) relative to non-Aboriginal (6.9 and 4.1 per 1000, respectively) births (all p<0.001). Compared to non-Aboriginal births, preterm birth rates were persistently (1.7–1.8 times) higher in Inuit, large-for-gestational-age birth rates were persistently (2.7–3.0 times) higher in First Nations births over the study period. Between 1996–2000 and 2006–2010, as compared to non-Aboriginal infants, the relative risk disparities increased for infant mortality (from 4.10 to 5.19 times) in Inuit, and for postneonatal mortality in Inuit (from 6.97 to 12.33 times) or First Nations (from 3.76 to 4.25 times) infants. Adjusting for maternal characteristics (age, marital status, parity, education and rural vs. urban residence) attenuated the risk differences, but significantly elevated risks remained in both Inuit and First Nations births for the risks of perinatal mortality (1.70 and 1.28 times, respectively), infant mortality (3.66 and 1.47 times, respectively) and postneonatal mortality (6.01 and 2.28 times, respectively) in Inuit and First Nations infants (all p<0.001).

Conclusions

Aboriginal vs. non-Aboriginal disparities in adverse birth outcomes, perinatal and infant mortality are persistent or worsening over the recent decade in Quebec, strongly suggesting the needs for interventions to improve perinatal and infant health in Aboriginal populations, and for monitoring the trends in other regions in Canada.     

Perinatal mortality in eastern Uganda: a community based prospective cohort study

Background

To achieve a child mortality reduction according to millennium development goal 4, it is necessary to considerably reduce neonatal mortality. We report stillbirth and early neonatal mortality risks as well as determinants of perinatal mortality in Eastern Uganda.

Methods

A community-based prospective cohort study was conducted between 2006 and 2008. A total of 835 pregnant women were followed up for pregnancy outcome and survival of their children until 7 days after delivery. Mother''s residence, age, parity, bed net use and whether delivery took place at home were included in multivariable regression analyses to identify risk factors for perinatal death.

Results

The stillbirth risk was 19 per 1,000 pregnancies and the early neonatal death risk 22 per 1,000 live births. Overall, the perinatal mortality risk was 41 [95%CI: 27, 54] per 1,000 pregnancies. Of the deaths, 47% followed complicated deliveries and 24% preterm births. Perinatal mortality was 63/1,000 pregnancies among teenage mothers, 76/1,000 pregnancies among nulliparous women and 61/1,000 pregnancies among women delivering at home who, after controlling for potential confounders, had a 3.7 (95%CI: 1.8, 7.4) times higher perinatal mortality than women who gave birth in a health facility. This association was considerably stronger among nulliparous women [RR 8.0 (95%CI: 2.9, 21.6)] than among women with a previous live birth [RR 1.8 (95%CI: 0.7, 4.5)]. All perinatal deaths occurred among women who did not sleep under a mosquito net. Women living in urban slums had a higher risk of losing their babies than those in rural areas [RR: 2.7 (95%CI: 1.4, 5.3)].

Conclusion

Our findings strengthen arguments for ensuring that pregnant women have access to and use adequate delivery facilities and bed nets.