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.     

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.     

Home births in England and Wales, 1979: perinatal mortality according to intended place of delivery.

A survey was carried out of all 8856 births occurring at home in England and Wales in 1979. Of these births, 67% had been booked for delivery at home, 21% had been booked for delivery in hospital, 3% had not been booked, and for 9% the intended place of delivery was unknown. The perinatal mortality varied almost 50-fold according to the intended place of delivery, ranging from 4.1/1000 births in those booked for delivery at home to 196.6/1000 unbooked births. Deliveries that occurred at home but had been booked for a hospital consultant unit were associated with a perinatal mortality of 67.5/1000. Births that had been booked for delivery at home included the smallest proportion of babies of low birth weight: 2.5% weighed 2500 g or less compared with 18% of those booked for consultant units and 29% of those not booked. Within these low birthweight groups there were noticeable differences in perinatal mortality; births booked to occur at home had the lowest mortality and unbooked births had the highest. Perinatal mortality among babies who weighed more than 2500 g was generally low irrespective of the intended place of delivery; the only exception was in babies whose delivery had not been booked. In all groups perinatal mortality was considerably higher in nulliparous than parous women. Women booking a delivery at home are clearly a selected group, and some may have been transferred to hospital during labour and were thus not included in the survey. Nevertheless, these data suggest that the perinatal mortality among births booked to occur at home is low, especially for parous women.     

Evaluating perinatal mortality rates: effects of referral and case mix.

OBJECTIVE--To evaluate perinatal mortality rates as a method of auditing obstetric and neonatal care after account had been taken of transfer between hospitals during pregnancy and case mix. DESIGN--Case-control study of perinatal deaths. SETTING--Leicestershire health district. SUBJECTS--1179 singleton perinatal deaths and their selected live born controls among 114,362 singleton births to women whose place of residence was Leicestershire during 1978-87. MAIN OUTCOME MEASURE--Crude perinatal mortality rates and rates adjusted for case mix. RESULTS--An estimated 11,701 of the 28,750 women booked for delivery in general practitioner maternity units were transferred to consultant units during their pregnancy. These 11,701 women had a high perinatal mortality rate (16.8/1000 deliveries). Perinatal mortality rates by place of booking showed little difference between general practitioner units (8.8/1000) and consultant units (9.3-11.7/1000). Perinatal mortality rates by place of delivery, however, showed substantial differences between general practitioner units (3.3/1000) and consultant units (9.4-12.6/1000) because of the selective referral of high risk women from general practitioner units to consultant units. Adjustment for risk factors made little difference to the rates except when the subset of deaths due to immaturity was adjusted for birth weight. CONCLUSION--Perinatal mortality rates should be adjusted for case mix and referral patterns to get a meaningful result. Even when this is done it is difficult to compare the effectiveness of hospital units with perinatal mortality rates because of the increasingly small subset of perinatal deaths that are amenable to medical intervention.     

Planned and unplanned deliveries at home: implications of a changing ratio.

The observation that perinatal mortality among babies delivered at home has tended to increase beyond that among babies delivered in consultant obstetric units has caused alarm and prompted recommendations that delivery at home should be further phased out. With data derived from the Cardiff Births Survey the possibility was investigated that this trend might reflect a changing ratio of planned to unplanned domiciliary births. At the beginning of the 1970s deliveries at home that were planned to be so outnumbered those that were not by nearly five to one. By 1979 unplanned deliveries at home outnumbered planned deliveries. The characteristics of the mothers, the health care they received, and the outcome of delivery differed strikingly between planned and unplanned deliveries at home. It is concluded, firstly, that every year the maternity services must try to meet the various needs of about 2000 women in England and Wales who give birth at home without planning to do so; and, secondly, that the heterogeneity of births at home and in hospital will continue to obstruct the search for unbiased estimates of the risks attributable to delivery in specialist obstetric units, general practitioner units, and at home.     

Home versus hospital deliveries: follow up study of matched pairs for procedures and outcome. Zurich Study Team.

OBJECTIVE: To assess procedures and outcomes in deliveries planned at home versus those planned in hospital among women choosing the place of delivery. DESIGN: Follow up study of matched pairs. SETTING: Antenatal clinics and reference hospitals in Zurich between 1989 and 1992. SUBJECTS: 489 women opting for home delivery and 385 opting for hospital delivery; the women comprised all those attending members of the study team for antenatal care and those attending the reference hospital for antenatal care who could be matched with the women planning home confinement. MAIN OUTCOME MEASURES: Need for medication and incidence of interventions during delivery (caesarean section, forceps, vacuum extraction, episiotomy), duration of labour, occurrence of severe perineal lesions, maternal blood loss, and perinatal morbidity and death. RESULTS: All women were followed up from their first antenatal visit till three months after delivery. Referrals during pregnancy (n = 37) and labour (70), changes of mind (15 home to hospital, eight hospital to home), and 17 miscarriages resulted in 369 births occurring at home and 486 in hospital. During delivery the home birth group needed significantly less medication and fewer interventions whereas no differences were found in durations of labour, occurrence of severe perineal lesions, and maternal blood loss. Perinatal death was recorded in one planned hospital delivery and one planned home delivery (overall perinatal mortality 2.3/1000). There was no difference between home and hospital delivered babies in birth weight, gestational age, or clinical condition. Apgar scores were slightly higher and umbilical cord pH lower in home births, but these differences may have been due to differences in clamping and the time of transportation. CONCLUSION: Healthy low risk women who wish to deliver at home have no increased risk either to themselves or to their babies.     

Birth order,gestational age,and risk of delivery related perinatal death in twins: retrospective cohort study

ObjectiveTo determine whether twins born second are at increased risk of perinatal death because of complications during labour and delivery.DesignRetrospective cohort study.SettingScotland, 1992 and 1997.ParticipantsAll twin births at or after 24 weeks'' gestation, excluding twin pairs in which either twin died before labour or delivery or died during or after labour and delivery because of congenital abnormality, non-immune hydrops, or twin to twin transfusion syndrome.ResultsOverall, delivery related perinatal deaths were recorded for 23 first twins only and 23 second twins only of 1438 twin pairs born before 36 weeks (preterm) by means other than planned caesarean section (P>0.99). No deaths of first twins and nine deaths of second twins (P=0.004) were recorded among the 2436 twin pairs born at or after 36 weeks (term). Discordance between first and second twins differed significantly in preterm and term births (P=0.007). Seven of nine deaths of second twins at term were due to anoxia during the birth (2.9 (95% confidence interval 1.2 to 5.9) per 1000); five of these deaths were associated with mechanical problems with the second delivery following vaginal delivery of the first twin. No deaths were recorded among 454 second twins delivered at term by planned caesarean section.ConclusionsSecond twins born at term are at higher risk than first twins of death due to complications of delivery. Previous studies may not have shown an increased risk because of inadequate categorisation of deaths, lack of statistical power, inappropriate analyses, and pooling of data about preterm births and term births.

What is already known on this topic

It is difficult to assess the wellbeing of second twins during labourDeliveries of second twins are at increased risk of mechanical problems, such as cord prolapse and malpresentation, after vaginal delivery of first twinsIncreased risks of perinatal death in second twins have not been shown, but the methods of these studies were flawed

What this study adds

Second twins delivered at term are at increased risk of delivery related perinatal deathsIntrapartum anoxia caused 75% of these deaths in second twins, and most of these resulted from mechanical problems after vaginal delivery of first twinsPlanned caesarean section of twins at term may prevent perinatal deaths     

Collaborative survey of perinatal loss in planned and unplanned home births. Northern Region Perinatal Mortality Survey Coordinating Group.

OBJECTIVE: To document the outcome of planned and unplanned births outside hospital. DESIGN: Confidential review of every pregnancy ending in stillbirth or neonatal death in which plans had been made for home delivery, irrespective of where delivery eventually occurred. The review was part of a sustained collaborative survey of all perinatal deaths. SETTING: Northern Regional Health Authority area. SUBJECTS: All 558,691 registered births to women normally resident in the former Northern Regional Health Authority area during 1981-94. MAIN OUTCOME MEASURE: Perinatal death. RESULTS: The estimated perinatal mortality during 1981-94 among women booked for a home birth was 14 deaths in 2888 births. This was less than half that among all women in the region. Only three of the 14 women delivered outside hospital. Independent review suggested that two of the 14 deaths might have been averted by different management. Both births occurred in hospital, and in only one was management before admission of the mother judged inappropriate. Perinatal loss to the 64 women who booked for hospital delivery but delivered outside and to the 67 women who delivered outside hospital without ever making arrangements to receive professional care during labour accounted for the high perinatal mortality (134 deaths in 3466 deliveries) among all births outside hospital. CONCLUSIONS: The perinatal hazard associated with planned home birth in the few women who exercised this option (< 1%) was low and mostly unavoidable. Health authorities purchasing maternity care need to address the much greater hazard associated with unplanned delivery outside hospital.     

Vertical transmission rates for HIV in the British Isles: estimates based on surveillance data

ObjectiveTo estimate and interpret time trends in vertical transmission rates for HIV using data from national obstetric and paediatric surveillance registers.DesignProspective study of HIV infected women reported through obstetric surveillance. HIV infection status of the child and onset of AIDS were reported through paediatric surveillance. Rates of vertical transmission and progression to AIDS rate were estimated by methods that take account of incomplete follow up of children with indeterminate infection status and delay in AIDS reporting.SettingBritish Isles.SubjectsPregnant women infected with HIV whose infection was diagnosed before delivery, and their babies.ResultsBy January 1999, 800 children born to diagnosed HIV infected women who had not breast fed had been reported. Vertical transmission rates rose to 19.6% (95% confidence interval 8.0% to 32.5%) in 1993 before falling to 2.2% (0% to 7.8%) in 1998. Between 1995 and 1998 use of antiretroviral treatment increased significantly each year, reaching 97% of live births in 1998. The rate of elective caesarean section remained constant, at around 40%, up to 1997 but increased to 62% in 1998. Caesarean section and antiretroviral treatment together were estimated to reduce risk of transmission from 31.6% (13.6% to 52.2%) to 4.2% (0.8% to 8.5%). The proportion of infected children developing AIDS in the first 6 months fell from 17.7% (6.8% to 30.8%) before 1994 to 7.2% (0% to 15.7%) after, coinciding with increased use of prophylaxis against Pneumocystis carinii pneumonia.ConclusionsIn the British Isles both HIV related morbidity and vertical transmission are being reduced through increased use of interventions.

Key messages

• Reliable estimates of HIV vertical transmission rates can be derived from surveillance data
• Infected pregnant women are increasingly taking up elective caesarean section and antiretroviral treatment to reduce the risk of transmitting HIV to their babies
• Vertical transmission rates have fallen greatly over the past four years and progression to AIDS among infected children may also have slowed
• These benefits can occur only if infected women are diagnosed before or during pregnancy

     

Births in Great Britain resulting from assisted conception, 1978-87. MRC Working Party on Children Conceived by In Vitro Fertilisation.

OBJECTIVE--To describe the characteristics at birth of children conceived by in vitro fertilisation (IVF) or by gamete intrafallopian transfer (GIFT) and to assess whether they differ from those of children conceived naturally. DESIGN--Survey of children resulting from IVF or GIFT and comparison of their characteristics at birth with national statistics. SETTING--England, Scotland, and Wales from 1978 to 1987. SUBJECTS--1267 Pregnancies conceived by IVF or GIFT, which resulted in 1581 liveborn or stillborn children. MAIN OUTCOME MEASURES--Sex ratio, multiplicity, gestational age at birth, birth weight, stillbirth rate, perinatal and infant mortality, and prevalence of congenital malformations. RESULTS--The ratio of male to female births was 1.07:1; 23% (249/1092) of the deliveries were multiple births compared with 1% for natural conceptions; 24% (278) of 1015 deliveries were preterm compared with 6% in England and Wales; 32% (406) of 1269 babies weighed less than 2500 g compared with 7% in England and Wales. The high percentage of preterm deliveries and of low birthweight babies was largely, but not entirely, due to the high frequency of multiple births. The rate of stillbirth, perinatal mortality, and infant mortality were twice the national average, these excesses being due to the high frequency of multiple births. One or more major congenital malformations were detected during the first week of life in 35 (2.2%) of 1581 babies. This figure is comparable with population based estimates of the prevalence of congenital malformations. The types of malformations reported varied, and the number of each specific type was small. The health of the children was not evaluated beyond the perinatal period. CONCLUSIONS--Multiple pregnancies often result from assisted conception and are the main determinant of the outcome of the pregnancies and of the health of the children at the time of birth. Congenital malformations are comparatively rare, so larger numbers of children need to be studied before firm conclusions can be drawn. The pooling of data from different countries is recommended.     

Influence of birth weight on differences in infant mortality by social class and legitimacy.

OBJECTIVE--To investigate the influence of birth weight on the pronounced social class differences in infant mortality in Britain. DESIGN--Analysis of routine data on births and infant deaths. SETTING--England and Wales. SUBJECTS--All live births and infant deaths, 1983-5. MAIN OUTCOME MEASURE--Mortality in infants by social class, birth weight, and legitimacy according to birth and death certificates. RESULTS--Neonatal and postneonatal mortality (deaths/1000 births) increased with social class. Neonatal and postneonatal mortality was 4.2/1000 and 2.3/1000 respectively for social class I and 6.8/1000 and 5.6/1000 respectively for social class V. Mortality was lower among births registered within marriage (postneonatal 3.5/1000; neonatal 5.2/1000) than among those jointly registered outside marriage (5.1/1000; 6.4/1000); mortality was highest in those solely registered outside marriage (7.2/1000; 7.0/1000). For neonatal mortality the effect of social class varied with birth weight. Social class had little effect on neonatal mortality in low birthweight babies and increasing effect in heavier babies. For postneonatal mortality the effect of social class was similar for all birth weights and was almost as steep as for all birth weights combined. CONCLUSION--Birth weight mediates little of the effect of social class on postneonatal mortality.     

Associations between cesarean delivery and child mortality: A national record linkage longitudinal study of 17.8 million births in Brazil

BackgroundThere is an increasing use of cesarean delivery (CD) based on preference rather than on medical indication. However, the extent to which nonmedically indicated CD benefits or harms child survival remains unclear. Our hypothesis was that in groups with a low indication for CD, this procedure would be associated with higher child mortality and in groups with a clear medical indication CD would be associated with improved child survival chances.Methods and findingsWe conducted a population-based cohort study in Brazil by linking routine data on live births between January 1, 2012 and December 31, 2018 and assessing mortality up to 5 years of age. Women with a live birth who contributed records during this period were classified into one of 10 Robson groups based on their pregnancy and delivery characteristics. We used propensity scores to match CD with vaginal deliveries (1:1) and prelabor CD with unscheduled CD (1:1) and estimated associations with child mortality using Cox regressions. A total of 17,838,115 live births were analyzed. After propensity score matching (PSM), we found that live births to women in groups with low expected frequencies of CD (Robson groups 1 to 4) had a higher death rate up to age 5 years if they were born via CD compared with vaginal deliveries (HR = 1.25, 95% CI: 1.22 to 1.28; p < 0.001). The relative rate was greatest in the neonatal period (HR = 1.39, 95% CI: 1.34 to 1.45; p < 0.001). There was no difference in mortality rate when comparing offspring born by a prelabor CD to those born by unscheduled CD. For the live births to women with a CD in a prior pregnancy (Robson group 5), the relative rates for child mortality were similar for those born by CD compared with vaginal deliveries (HR = 1.05, 95% CI: 1.00 to 1.10; p = 0.024). In contrast, for live births to women in groups with high expected rates of CD (Robson groups 6 to 10), the child mortality rate was lower for CD than for vaginal deliveries (HR = 0.90, 95% CI: 0.89 to 0.91; p < 0.001), particularly in the neonatal period (HR = 0.84, 95% CI: 0.83 to 0.85; p < 0.001). Our results should be interpreted with caution in clinical practice, since relevant clinical data on CD indication were not available.ConclusionsIn this study, we observed that in Robson groups with low expected frequencies of CD, this procedure was associated with a 25% increase in child mortality. However, in groups with high expected frequencies of CD, the findings suggest that clinically indicated CD is associated with a reduction in child mortality.

In a study of linked population-based data, Enny Paixao and colleagues study the associations between cesarean section and child mortality among 17.8 million live births in Brazil.     

Neonatal mortality and prevalence of practices for newborn care in a squatter settlement of Karachi, Pakistan: a cross-sectional study

Background

During the past two decades there has been a sustained decline in child and infant mortality, however neonatal mortality has remained relatively unchanged. Almost all neonatal deaths (99%) occur in developing countries, where the majority are delivered at homes. Evidence suggests that these deaths could be prevented by simple, inexpensive practices and interventions during the pregnancy, delivery and postnatal period. In Pakistan over the last decade extensive efforts have been made by the international donors and government to implement these practices. However, limited attempts have been made to explore if these efforts have made a difference at the grass root level. This study assessed the burden of neonatal mortality and prevalence of practices for newborn care in a squatter settlement of Karachi, Pakistan.

Methodology/Principal Findings

A community based cross-sectional study was performed. A pre-tested structured questionnaire was administered to 565 women who had recently delivered. Information was collected on neonatal morbidity, mortality and practices of women regarding care during pregnancy, child birth and for newborn, till 28th day of birth. Although 70% of women mentioned receiving antenatal care by a skilled provider, only 54.5% had four or more visits. Tetanus toxoid was received by 79% of women while only 56% delivered at a health care facility by a skilled attendant. Newborn care practices like bathing the baby immediately after birth (56%), giving pre-lacteals (79.5%), late initiation of breast feeding (80.3%), application of substances on umbilical cord (58%) and body massage (89%) were common. Most neonates (81.1%) received BCG injection and polio drops after birth. Neonatal mortality rate was 27/1000 live births with the majority of deaths occurring during the first three days of life.

Conclusion

Even after years of efforts by government and nongovernmental sector to reduce newborn morbidity and mortality, inadequate antenatal care, home deliveries and unhealthy newborn care practices are highly prevalent. This leads us to important questions of why practices and behaviors have not changed. Who is responsible and what strategies are needed to bring this change?     

Congenital malformations at birth in Central India: A rural medical college hospital based data

OBJECTIVE:

To study the incidence of congenital anomalies and the associated risk factors in Department of Pediatrics at Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, a rural medical college hospital in central Maharashtra.

MATERIALS AND METHODS:

All the intramural deliveries between 1 January 2005 and 31 July 2007 comprised 9386 births and their 9324 mothers (62 mothers gave birth to twin babies). The newborns were examined and assessed systematically for the presence of congenital anomalies, system wise distribution of anomalies and risk factors attributable.

RESULTS:

Out of the total 9386 deliveries, 9194 were live births and 192 were stillbirths. The total number of babies with congenital malformations was 179 (1.91%). Out of the 9262 singleton births, 177 (1.05%) were malformed, whereas 2 of the 62 pairs of twins had birth defects. Nine of the 179 malformed babies (5.02%) were still born. Prematurity, increased maternal age, increasing birth order and low birth weight were found to have a higher risk of congenital anomalies. Cardiovascular malformations were most common in live births, followed by musculoskeletal and genitourinary anomalies.

CONCLUSION:

Congenital anomalies are a major cause of stillbirths and infant mortality. Evaluation of cardiovascular system to rule out congenital heart disease in high-risk mothers’ babies is the important factor to be considered.     

The influence of distance and level of care on delivery place in rural Zambia: a study of linked national data in a geographic information system

Background

Maternal and perinatal mortality could be reduced if all women delivered in settings where skilled attendants could provide emergency obstetric care (EmOC) if complications arise. Research on determinants of skilled attendance at delivery has focussed on household and individual factors, neglecting the influence of the health service environment, in part due to a lack of suitable data. The aim of this study was to quantify the effects of distance to care and level of care on women''s use of health facilities for delivery in rural Zambia, and to compare their population impact to that of other important determinants.

Methods and Findings

Using a geographic information system (GIS), we linked national household data from the Zambian Demographic and Health Survey 2007 with national facility data from the Zambian Health Facility Census 2005 and calculated straight-line distances. Health facilities were classified by whether they provided comprehensive EmOC (CEmOC), basic EmOC (BEmOC), or limited or substandard services. Multivariable multilevel logistic regression analyses were performed to investigate the influence of distance to care and level of care on place of delivery (facility or home) for 3,682 rural births, controlling for a wide range of confounders. Only a third of rural Zambian births occurred at a health facility, and half of all births were to mothers living more than 25 km from a facility of BEmOC standard or better. As distance to the closest health facility doubled, the odds of facility delivery decreased by 29% (95% CI, 14%–40%). Independently, each step increase in level of care led to 26% higher odds of facility delivery (95% CI, 7%–48%). The population impact of poor geographic access to EmOC was at least of similar magnitude as that of low maternal education, household poverty, or lack of female autonomy.

Conclusions

Lack of geographic access to emergency obstetric care is a key factor explaining why most rural deliveries in Zambia still occur at home without skilled care. Addressing geographic and quality barriers is crucial to increase service use and to lower maternal and perinatal mortality. Linking datasets using GIS has great potential for future research and can help overcome the neglect of health system factors in research and policy. Please see later in the article for the Editors'' Summary     

Uterine Rupture by Intended Mode of Delivery in the UK: A National Case-Control Study

Background

Recent reports of the risk of morbidity due to uterine rupture are thought to have contributed in some countries to a decrease in the number of women attempting a vaginal birth after caesarean section. The aims of this study were to estimate the incidence of true uterine rupture in the UK and to investigate and quantify the associated risk factors and outcomes, on the basis of intended mode of delivery.

Methods and Findings

A UK national case-control study was undertaken between April 2009 and April 2010. The participants comprised 159 women with uterine rupture and 448 control women with a previous caesarean delivery. The estimated incidence of uterine rupture was 0.2 per 1,000 maternities overall; 2.1 and 0.3 per 1,000 maternities in women with a previous caesarean delivery planning vaginal or elective caesarean delivery, respectively. Amongst women with a previous caesarean delivery, odds of rupture were also increased in women who had ≥ two previous caesarean deliveries (adjusted odds ratio [aOR] 3.02, 95% CI 1.16–7.85) and <12 months since their last caesarean delivery (aOR 3.12, 95% CI 1.62–6.02). A higher risk of rupture with labour induction and oxytocin use was apparent (aOR 3.92, 95% CI 1.00–15.33). Two women with uterine rupture died (case fatality 1.3%, 95% CI 0.2–4.5%). There were 18 perinatal deaths associated with uterine rupture among 145 infants (perinatal mortality 124 per 1,000 total births, 95% CI 75–189).

Conclusions

Although uterine rupture is associated with significant mortality and morbidity, even amongst women with a previous caesarean section planning a vaginal delivery, it is a rare occurrence. For women with a previous caesarean section, risk of uterine rupture increases with number of previous caesarean deliveries, a short interval since the last caesarean section, and labour induction and/or augmentation. These factors should be considered when counselling and managing the labour of women with a previous caesarean section. Please see later in the article for the Editors'' Summary     

Science commentary: Behaviour of hepatitis C virus

Objective: To determine the risk factors for and timing of vertical transmission of hepatitis C virus in women who are not infected with HIV-1. Design: Follow up for a median of 28 (range 24-38) months of babies born to women with antibodies to hepatitis C virus but not HIV-1. Subjects: 442 mothers and babies, of whom 403 completed the study. Main outcome measures: Presence of antibodies to hepatitis C virus and viral RNA and alanine aminotransferase activity in babies. Presence of viral RNA, method of infection with hepatitis C, method of delivery, and type of infant feeding in mothers.Results: 13 of the 403 children had acquired hepatitis C virus infection at the end of follow up. All these children were born to women positive for hepatitis C virus RNA; none of the 128 RNA negative mothers passed on the infection (difference 5%, 95% confidence interval 2% to 7%). 6 children had viral RNA immediately after birth. 111 women had used intravenous drugs and 20 had received blood transfusions. 11 of the infected children were born to these women compared with 2 to the 144 with no known risk factor (difference 7%, 2% to 12%).Conclusions: This study suggests that in women not infected with HIV only those with hepatitis C virus RNA are at risk of infecting their babies. Transmission does seem to occur in utero, and the rate of transmission is higher in women who have had blood transfusions or used intravenous drugs than in women with no known risk factor for infection.

Key messages

• Little information exists on vertical transmission of hepatitis C virus in women not infected with HIV
• This study in a large unselected population of infants born to HIV-1 negative mothers suggests that intravenous drug use itself is an important risk factor for transmission of hepatitis C virus
• Maternal post-transfusional hepatitis is also an important risk factor for infection of infants
• Viral genotype, maternal viraemia, type of delivery (vaginal delivery or caesarean section) and breast feeding do not seem to be risk factors
• In utero transmission of hepatitis C virus has been suggested by RNA positivity on day of birth in some infected children

     

A large cross-sectional community-based study of newborn care practices in southern Tanzania

Despite recent improvements in child survival in sub-Saharan Africa, neonatal mortality rates remain largely unchanged. This study aimed to determine the frequency of delivery and newborn-care practices in southern Tanzania, where neonatal mortality is higher than the national average. All households in five districts of Southern Tanzania were approached to participate. Of 213,220 female residents aged 13-49 years, 92% participated. Cross-sectional, retrospective data on childbirth and newborn care practices were collected from 22,243 female respondents who had delivered a live baby in the preceding year. Health facility deliveries accounted for 41% of births, with nearly all non-facility deliveries occurring at home (57% of deliveries). Skilled attendants assisted 40% of births. Over half of women reported drying the baby and over a third reported wrapping the baby within 5 minutes of delivery. The majority of mothers delivering at home reported that they had made preparations for delivery, including buying soap (84%) and preparing a cloth for drying the child (85%). Although 95% of these women reported that the cord was cut with a clean razor blade, only half reported that it was tied with a clean thread. Furthermore, out of all respondents 10% reported that their baby was dipped in cold water immediately after delivery, around two-thirds reported bathing their babies within 6 hours of delivery, and 28% reported putting something on the cord to help it dry. Skin-to-skin contact between mother and baby after delivery was rarely practiced. Although 83% of women breastfed within 24 hours of delivery, only 18% did so within an hour. Fewer than half of women exclusively breastfed in the three days after delivery. The findings suggest a need to promote and facilitate health facility deliveries, hygienic delivery practices for home births, delayed bathing and immediate and exclusive breastfeeding in Southern Tanzania to improve newborn health.     

Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery

ObjectivesTo determine whether preoperative optimisation of oxygen delivery improves outcome after major elective surgery, and to determine whether the inotropes, adrenaline and dopexamine, used to enhance oxygen delivery influence outcome.DesignRandomised controlled trial with double blinding between inotrope groups.SettingYork District Hospital, England.Subjects138 patients undergoing major elective surgery who were at risk of developing postoperative complications either because of the surgery or the presence of coexistent medical conditions.InterventionsPatients were randomised into three groups. Two groups received invasive haemodynamic monitoring, fluid, and either adrenaline or dopexamine to increase oxygen delivery. Inotropic support was continued during surgery and for at least 12 hours afterwards. The third group (control) received routine perioperative care.ResultsOverall, 3/92 (3%) preoptimised patients died compared with 8/46 controls (17%) (P=0.007). There were no differences in mortality between the treatment groups, but 14/46 (30%) patients in the dopexamine group developed complications compared with 24/46 (52%) patients in the adrenaline group (difference 22%, 95% confidence interval 2% to 41%) and 28 patients (61%) in the control group (31%, 11% to 50%). The use of dopexamine was associated with a decreased length of stay in hospital.ConclusionRoutine preoperative optimisation of patients undergoing major elective surgery would be a significant and cost effective improvement in perioperative care.

Key messages

• Major elective surgery in UK general hospitals still carries significant mortality and morbidity
• Preoperative administration of fluid and inotropes, guided by invasive monitoring, can significantly reduce mortality, morbidity, and length of hospital stay
• The choice of inotrope may influence the extent of improvements in outcome
• Routine preoperative optimisation would require initial investment in high dependency care facilities but is likely to be cost effective by reducing complications and length of hospital stay

     

Double blind, cluster randomised trial of low dose supplementation with vitamin A or beta carotene on mortality related to pregnancy in Nepal. The NNIPS-2 Study Group

ObjectiveTo assess the impact on mortality related to pregnancy of supplementing women of reproductive age each week with a recommended dietary allowance of vitamin A, either preformed or as β carotene.DesignDouble blind, cluster randomised, placebo controlled field trial.SettingRural southeast central plains of Nepal (Sarlahi district).Subjects44 646 married women, of whom 20 119 became pregnant 22 189 times.Intervention270 wards randomised to 3 groups of 90 each for women to receive weekly a single oral supplement of placebo, vitamin A (7000 μg retinol equivalents) or β carotene (42 mg, or 7000 μg retinol equivalents) for over 3½ years.ResultsMortality related to pregnancy in the placebo, vitamin A, and β carotene groups was 704, 426, and 361 deaths per 100 000 pregnancies, yielding relative risks (95% confidence intervals) of 0.60 (0.37 to 0.97) and 0.51 (0.30 to 0.86). This represented reductions of 40% (P<0.04) and 49% (P<0.01) among those who received vitamin A and β carotene. Combined, vitamin A or β carotene lowered mortality by 44% (0.56 (0.37 to 0.84), P<0.005) and reduced the maternal mortality ratio from 645 to 385 deaths per 100 000 live births, or by 40% (P<0.02). Differences in cause of death could not be reliably distinguished between supplemented and placebo groups.ConclusionSupplementation of women with either vitamin A or β carotene at recommended dietary amounts during childbearing years can lower mortality related to pregnancy in rural, undernourished populations of south Asia.

Key messages

• Maternal vitamin A deficiency, evident as night blindness or low serum retinol concentration during pregnancy, is widely prevalent in rural south Asia
• In Nepal, women of reproductive age who were given 7000 μg retinol equivalents of vitamin A on a weekly basis showed a reduction in mortality related to pregnancy of 40%
• Weekly dosing with 42 mg β carotene (also providing 7000 μg retinol equivalents) lowered their mortality by 49%
• Preventing maternal vitamin A deficiency in rural South Asia can lower the risk of mortality of women during and after pregnancy