Contribution of preterm delivery to perinatal mortality.

A detailed retrospective analysis was made of the records of 486 preterm infants, who accounted for 5-1% of all births during 1973 and 1974. Whereas preterm delivery did not contribute to perinatal mortality in terms of stillbirth, it outweighed all other causes in terms of early neonatal deaths. Preterm birth was responsible for 85% of the early neonatal deaths not due to lethal congenital deformities. Early neonatal mortality rates were closely linked both to gestational age and birth weight and to the reason for preterm birth. Early neonatal mortality was high (97 per 1000) when preterm labour was spontaneous, whether or not associated with material or fetal disease or with multiple pregnancy, but low (27 per 1000) when preterm delivery was elective. Preventing spontaneous preterm labour would considerably reduce neonatal mortality in our community.     

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.     

Why Are Babies Dying in the First Month after Birth? A 7-Year Study of Neonatal Mortality in Northern Ghana

Objectives

To determine the neonatal mortality rate in the Kassena-Nankana District (KND) of northern Ghana, and to identify the leading causes and timing of neonatal deaths.

Methods

The KND falls within the Navrongo Health Research Centre’s Health and Demographic Surveillance System (HDSS), which uses trained field workers to gather and update health and demographic information from community members every four months. We utilized HDSS data from 2003–2009 to examine patterns of neonatal mortality.

Results

A total of 17,751 live births between January 2003 and December 2009 were recorded, including 424 neonatal deaths 64.8%(275) of neonatal deaths occurred in the first week of life. The overall neonatal mortality rate was 24 per 1000 live births (95%CI 22 to 26) and early neonatal mortality rate was 16 per 1000 live births (95% CI 14 to 17). Neonatal mortality rates decreased over the period from 26 per 1000 live births in 2003 to 19 per 1000 live births in 2009. In all, 32%(137) of the neonatal deaths were from infections, 21%(88) from birth injury and asphyxia and 18%(76) from prematurity, making these three the leading causes of neonatal deaths in the area. Birth injury and asphyxia (31%) and prematurity (26%) were the leading causes of early neonatal deaths, while infection accounted for 59% of late neonatal deaths. Nearly 46% of all neonatal deaths occurred during the first three postnatal days. In multivariate analysis, multiple births, gestational age <32 weeks and first pregnancies conferred the highest odds of neonatal deaths.

Conclusions

Neonatal mortality rates are declining in rural northern Ghana, with majority of deaths occurring within the first week of life. This has major policy, programmatic and research implications. Further research is needed to better understand the social, cultural, and logistical factors that drive high mortality in the early days following delivery.     

The influence of antenatal and maternal factors on stillbirths and neonatal deaths in New South Wales, Australia

This study identified the influences of maternal socio-demographic and antenatal factors on stillbirths and neonatal deaths in New South Wales, Australia. Bivariate and multivariate analyses were used to explore the association of selected antenatal and maternal characteristics with stillbirths and neonatal deaths. The findings of this study showed that stillbirths and neonatal deaths significantly varied by infant sex, maternal age, Aboriginality, maternal country of birth, socioeconomic status, parity, maternal smoking behaviour during pregnancy, maternal diabetes mellitus, maternal hypertension, antenatal care, plurality of birth, low birth weight, place of birth, delivery type, maternal deaths and small gestational age. First-born infants, twins and infants born to teenage mothers, Aboriginal mothers, those who smoked during the pregnancy and those of lower socioeconomic status were at increased risk of stillbirths and neonatal deaths. The most common causes of stillbirths were conditions originating in the perinatal period: intrauterine hypoxia and asphyxia. Congenital malformations, including deformities and chromosomal abnormalities, and disorders related to slow fetal growth, short gestation and low birth weight were the most common causes of neonatal deaths. The findings indicate that very low birth weight (less than 2,000 g) contributed 75.6% of the population-attributable risks to stillbirths and 59.4% to neonatal deaths. Low gestational age (less than 32 weeks) accounted for 77.7% of stillbirths and 87.9% of neonatal deaths. The findings of this study suggest that in order to reduce stillbirths and neonatal deaths, it is essential to include strategies to predict and prevent prematurity and low birth weight, and that there is a need to focus on anti-smoking campaigns during pregnancy, optimizing antenatal care and other healthcare programmes targeted at the socially disadvantaged populations identified in this study.     

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.     

Determinants and Causes of Neonatal Mortality in Jimma Zone,Southwest Ethiopia: A Multilevel Analysis of Prospective Follow Up Study

Background

Ethiopia is among the countries with the highest neonatal mortality with the rate of 37 deaths per 1000 live births. In spite of many efforts by the government and other partners, non-significant decline has been achieved in the last 15 years. Thus, identifying the determinants and causes are very crucial for policy and program improvement. However, studies are scarce in the country in general and in Jimma zone in particular.

Objective

To identify the determinants and causes of neonatal mortality in Jimma Zone, Southwest Ethiopia.

Methods

A prospective follow-up study was conducted among 3463 neonates from September 2012 to December 2013. The data were collected by interviewer-administered structured questionnaire and analyzed by SPSS V.20.0 and STATA 13. Verbal autopsies were conducted to identify causes of neonatal death. Mixed-effects multilevel logistic regression model was used to identify determinants of neonatal mortality.

Results

The status of neonatal mortality rate was 35.5 (95%CI: 28.3, 42.6) per 1000 live births. Though significant variation existed between clusters in relation to neonatal mortality, cluster-level variables were found to have non-significant effect on neonatal mortality. Individual-level variables such as birth order, frequency of antenatal care use, delivery place, gestation age at birth, premature rupture of membrane, complication during labor, twin births, size of neonate at birth and neonatal care practice were identified as determinants of neonatal mortality. Birth asphyxia (47.5%), neonatal infections (34.3%) and prematurity (11.1%) were the three leading causes of neonatal mortality accounting for 93%.

Conclusions

This study revealed high status of neonatal mortality in the study area. Higher-level variables had less importance in determining neonatal mortality. Individual level variables related to care during pregnancy, intra-partum complications and care, neonatal conditions and the immediate neonatal care practices were identified as determinant factors. Improving antenatal care, intra-partum care and immediate neonatal care are recommended.     

Fetal and neonatal mortality: a matter of care? Report of a survey in Cura?ao,Netherlands Antilles.

A detailed clinicopathological analysis of 223 consecutive fetal and neonatal deaths was carried out in Curaçao during 1984 and 1985; this included careful histological examination of 210 infants (94%). The crude death rate was 34.2 per 1000 total births. Malformation was the principal cause of death in 28 cases, antepartum haemorrhage in 19, hypertension in 25, and asphyxia in 35. Death was caused by problems of preterm birth in 68 cases. No specific cause could be found for 34 deaths. Improvement in the quality of obstetric care might substantially reduce both fetal and neonatal death rates.     

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 mortality: a continuing collaborative regional survey.

A collaborative survey of perinatal mortality in each district of the Northern region set up in July 1980 was able to obtain information on 99% of all the registered perinatal deaths among babies born in 1981-2 to mothers resident in the region. There were 12.4 perinatal deaths/1000 births over this two year period, but 41% of the stillbirths and early neonatal deaths were of babies with a lethal malformation or weighing less than 1000 g at birth (or both). All causes of perinatal mortality had become less common than they had been at the time of the National Birthday Trust survey in 1958, though there had been a relatively small decrease in the number of deaths due to malformation (in the absence of any neural tube defect) and in the number of stillbirths of normally developed fetuses: 36% of the antepartum stillbirths among non-malformed singleton fetuses were associated with poor fetal growth (weight below the fifth centile at birth) and 21% were due to sudden unexplained placental abruption.     

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.     

Hospital delivery and neonatal mortality in 37 countries in sub-Saharan Africa and South Asia: An ecological study

BackgroundWidespread increases in facility delivery have not substantially reduced neonatal mortality in sub-Saharan Africa and South Asia over the past 2 decades. This may be due to poor quality care available in widely used primary care clinics. In this study, we examine the association between hospital delivery and neonatal mortality.Methods and findingsWe used an ecological study design to assess cross-sectional associations between the share of hospital delivery and neonatal mortality across country regions. Data were from the Demographic and Health Surveys from 2009 to 2018, covering 682,239 births across all regions. We assess the association between the share of facility births in a region that occurred in hospitals (versus lower-level clinics) and early (0 to 7 days) neonatal mortality per 1,000 births, controlling for potential confounders including the share of facility births, small at birth, maternal age, maternal education, urbanicity, antenatal care visits, income, region, and survey year. We examined changes in this association in different contexts of country income, global region, and urbanicity using interaction models.Across the 1,143 regions from 37 countries in sub-Saharan Africa and South Asia, 42%, 29%, and 28% of births took place in a hospital, clinic, and at home, respectively. A 10-percentage point higher share of facility deliveries occurring in hospitals was associated with 1.2 per 1,000 fewer deaths (p-value < 0.01; 95% CI: 0.82 to 1.60), relative to mean mortality of 22. Associations were strongest in South Asian countries, middle-income countries, and urban regions. The study’s limitations include the inability to control for all confounding factors given the ecological and cross-sectional design and potential misclassification of facility levels in our data.ConclusionsRegions with more hospital deliveries than clinic deliveries have reduced neonatal mortality. Increasing delivery in hospitals while improving quality across the health system may help to reduce high neonatal mortality.

In an ecological study, Anna D Gage and colleagues examine the association between hospital delivery and neonatal mortality in 37 countries in sub-Saharan Africa and South Asia.     

Risk factors for neonatal encephalopathy in Kathmandu, Nepal, a developing country: unmatched case-control study

This unmatched case-control study determined the risk factors for neonatal encephalopathy among term infants in Kathmandu, Nepal. Study participants included 131 infants with neonatal encephalopathy born between January 1995 and July 1996, and 635 unmatched infants systematically recruited over 12 months. The prevalence of neonatal encephalopathy was 6.1% per 1000 live births, of which 63% were infants with moderate encephalopathy. Antepartum risk factors included multiple births (odds ratio, OR = 22), primiparity (OR = 2.0), and nonattendance for antenatal care (OR = 2.1). Intrapartum risk factors were particulate meconium (OR = 18), noncephalic presentation (OR = 3.4), prolonged rupture of membranes (OR = 3.8), and other complications. In addition, induction of labor with oxytocin was associated with encephalopathy in 12 of 41 deliveries (OR = 5.7). Overall, 78 affected infants (60%) compared with 36 controls (6%) either had evidence of intrapartum compromise or were born after an intrapartum difficulty likely to result in fetal compromise. Moreover, maternal hemoglobin concentration 8.0 g/dl (OR = 2.5) and thyroid stimulating hormone 5 ml U/l (OR = 2.1) were associated with encephalopathy. Intrapartum risk factors remain important for neonatal encephalopathy in developing countries. There is some evidence of a protective effect from antenatal care. The use of oxytocin in low-income countries where intrapartum monitoring is suboptimal presents a major risk to the fetus. Further studies are required to explore the association between maternal deficiency states and neonatal encephalopathy.     

Contribution of twin pregnancy to perinatal mortality and fetal growth retardation; reversal of growth retardation after birth.

A survey of factors associated with perinatal mortality in 511 twins and fetal growth retardation and its reversal in 262 twins is presented. The incidence of stillbirth was almost 50% higher in twins than in singletons and the neonatal mortality was six times as high. Eighty percent of the neonatal deaths occurred in infants born prior to or at 30 weeks of gestation; 93% of the deaths were in infants weighing less than 1500 g and 75% occurred within 48 hours of birth. Fetal malnutrition was the main cause of stillbirth, and respiratory distress syndrome and asphyxia neonatorum were the main causes of neonatal death. One quarter of the twins had fetal growth retardation, a prevalence 10 times that in singletons. In almost all, the growth retardation was reversed by high-energy feedings. Although twins represented only 1% of all pregnancies and 2% of live births, they composed 12% of infants with early neonatal death and 17% of growth-retarded infants. A program is suggested for reduction of twin mortality and morbidity.     

Maternal and Antenatal Risk Factors for Stillbirths and Neonatal Mortality in Rural Bangladesh: A Case-Control Study

Objective

To identify maternal and antenatal factors associated with stillbirths and neonatal deaths in rural Bangladesh.

Study Design

A prospective cohort study is being conducted to evaluate a maternal and child nutrition program in rural Bangladesh. Cases were all stillbirths and neonatal deaths that occurred in the cohort between March 7, 2011 and December 30, 2011. Verbal autopsies were used to determine cause of death. For each case, four controls were randomly selected from cohort members alive at age 3-months. Multivariable logistic regression was used to identify factors associated with these deaths.

Results

Overall, 112 adverse pregnancy outcomes (44 stillbirths, 19/1,000 births; 68 neonatal deaths, 29/1,000 live births) were reported. Of the stillbirths 25 (56.8%) were fresh. The main causes of neonatal death were birth asphyxia (35%), sepsis (28%) and preterm birth (19%). History of bleeding during pregnancy was the strongest risk factor for stillbirths (adjusted odds ratio 22.4 [95% confidence interval 2.5, 197.5]) and neonatal deaths (adjusted odds ratio 19.6 [95% confidence interval 2.1, 178.8]). Adequate maternal nutrition was associated with decreased risk of neonatal death (adjusted odds ratio 0.4 [95% confidence interval 0.2, 0.8]).

Conclusions

Identifying high-risk pregnancies during gestation and ensuring adequate antenatal and obstetric care needs to be a priority for any community-based maternal and child health program in similar settings.     

Outcomes of pregnancy in insulin dependent diabetic women: results of a five year population cohort study.

OBJECTIVE: To monitor pregnancies in women with pre-existent insulin dependent diabetes for pregnancy loss, congenital malformations, and fetal growth in a geographically defined area of north west England. DESIGN: Population cohort study. SETTING: 10 maternity units in Cheshire, Lancashire, and Merseyside which had no regional guidelines for the management of pregnancy in diabetic women. SUBJECTS: 462 pregnancies in 355 women with insulin dependent diabetes from the 10 centres over five years (1990-4 inclusive). MAIN OUTCOME MEASURES: Numbers and rates of miscarriages, stillbirths, and neonatal and postneonatal deaths; prevalence of congenital malformations; birth weight in relation to gestational age. RESULTS: Among 462 pregnancies, 351 (76%) resulted in a liveborn infant, 78 (17%) aborted spontaneously, nine (2%) resulted in stillbirth, and 24 (5%) were terminated. Of the terminations, nine were for congenital malformation. The stillbirth rate was 25.0/1000 total births (95% confidence interval 8.9 to 41.1) compared with a population rate of 5.0/1000, and infant mortality was 19.9/1000 live births (5.3 to 34.6) compared with 6.8/1000. The prevalence of congenital malformations was 94.0/1000 live births (63.5 to 124.5) compared with 9.7/1000 in the general population. When corrected for gestational age, mean birth weight in the sample was 1.3 standard deviations greater than that of infants of non-diabetic mothers. Infants with congenital malformations weighed less than those without. CONCLUSION: In an unselected population the infants of women with pre-existent insulin dependent diabetes mellitus have a 10-fold greater risk of a congenital malformation and a fivefold greater risk of being stillborn than infants in the general population. Further improvements in the management of pregnancy in diabetic women are needed if target of the St Vincent declaration of 1989 is to be met.     

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.     

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.     

Should we abandon Kielland's forceps?

To assess the risks associated with the use of Kielland''s forceps 2708 consecutive deliveries were studied prospectively and the neonatal outcome related to the mode of delivery. Of the 1191 primigravidas, 279 (23.4%) underwent instrumental delivery, of whom 65 (5.5%) were delivered with Kielland''s forceps. There was no difference in early neonatal outcome (as judged by Apgar scores, intubations, and admission to the special care baby unit) between these babies and those delivered normally or by non-rotational forceps, but a higher proportion of the 127 (10.7%) delivered by emergency caesarean section were compromised. Of the 1517 multigravid patients, only 57 (3.8%) underwent instrumental delivery, 15 (1.0%) by Kielland''s forceps. Among these babies, also, the outcome was no worse than for those delivered normally, but the babies delivered by caesarean section showed a greatly increased incidence of low Apgar scores, intubations, and admission to the special care baby unit. There were no stillbirths or neonatal deaths among babies delivered by Kielland''s forceps, nor were there any cases of severe birth trauma or of obvious neonatal morbidity.