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This study analyzes the perinatal mortality statistics for the Maltese Islands since 1950 and compares them to those of other European countries. The mortality rate has taken a variable downward trend which can be correlated to important events during this period. Hospital perinatal mortality statistics are reviewed in the light of the national statistics.
In the Perinatal Unit of the New Jersey Medical School, Newark the combined neonatal mortality and stillbirth rates declined from more than 51 per 1000 to less than 17 per 1000 between 1971 and 1983. This change is comparable to the reduction of perinatal mortality rates nationwide since the Second World War. Because the improvement in the fetal and neonatal survival rates occurred in a static population and against well identifiable changes in the structure, equipment, policies and management patterns of the obstetric unit, it was possible to assess the impact of various factors upon perinatal outcome. In the environment of this institution adherence to conservative concepts of obstetric management, avoidance of manipulative and extraction procedures, an increase of the rate of cesarean sections from about 7 to 15% and emphasis upon infection control appeared to be the crucially important factors. Antepartum sonography and fetal stress and non-stress testing significantly impacted upon the results. The role of intrapartum electronic monitoring was less clearly definable and seemed to be effective only in the hands of experienced physicians. The results did not seem to be adversely affected by the fact that the program de-emphasized invasive procedures, including fetal scalp pH sampling.
Perinatal deaths, comprising stillbirths and deaths during the first week of life, were monitored over the eight-year period 1979 to 1986 in a rural Bangladeshi population of 196,000. The perinatal mortality rate was 75 per 1000 total births. The rate was 13% higher in males than females. Stillbirth and early neonatal mortality rates were 37 and 38 per 1000 total births, respectively. The major causes of perinatal deaths are presented, as well as some of the maternal determinants. During the period under study, perinatal mortality declined regularly and significantly over time in an area covered by an intensive Family Planning and Health Services programme, but not in the adjacent control area. This raises the issue of the impact of such a programme upon perinatal mortality, and the need to include a strong maternity care component into primary healthcare strategies if further reductions of perinatal mortality are to be achieved.
Hospital University Sains Malaysia (HUSM) functions as the state referral centre and the only hospital for the state of Kelantan that can offer neonatal intensive care service. The deliveries in HUSM with grand multiparity, late booking and problems of late referrals resembles a hospital serving a semiurban rather than an urban community. A comparison between the year 1989 and 1991 showed marked improvement of perinatal mortality rate from 41.32 to 24.88, which is significantly better than the improvement achieved from 1987 to 1989 (46.0 to 41.32). This was possible due to a marked fall in the early neonatal mortality rate from 10.02 in 1989 to 5.45 in 1991 and fall in the stillbirth rate from 31.61 to 19.53.
Prolonged labour was the most frequent cause of perinatal death in a rural hospital in the south western highlands of Tanzania. After the introduction of an obstetric policy aiming to prevent prolonged labour by making use of the guidelines of the partogram, perinatal mortality was reduced from 71 to 39 per 1000 births. Baird's clinico-pathological classification is still considered a useful instrument for the discovery of avoidable factors in perinatal deaths. The concept of the partogram should be an integral part of the training of medical auxiliaries in the field of maternal and child health (MCH).
The risk of perinatal death is displayed for '56 growth combinations', then contracted into 16 gestational age/birthweight categories (GA/BW) with additional control for antenatal visits (AV;CARE) for 36 000 singleton birth deliveries monitored in Indonesia from 1978-1980. For virtually all GA/BW combinations, the risk of perinatal death (PD) drops impressively with pregnancy care (Care effect on PD). Fetal growth curves are then displayed by infant outcome, the BW difference being the deficit birthweight (DBW) that may serve as a specific life-death growth standard (LDGS)--a reference system in relation to which fetal growth curves, to be controlled for factors other than infant outcome, may be studied. By controlling for maternal education and pregnancy care, the fetal growth curve associated with high pregnancy care and low education (HIAV/LOED) is more favorable than that for low pregnancy care and high education (LOAV/HIED). In Indonesia then, pregnancy care is more important than formal education in the reduction of not only perinatal mortality but also low birthweight (Care effect on fetal growth).
National trends in the survival of low birthweight infants for the years 1953 to 1979 were examined. While stillbirth and day 1-28 mortality rates improved steadily throughout this period, day 0 mortality did not start to fall until the mid-1960s and then it improved in all birthweight groups. This suggests that special and intensive baby care units introduced progressively since about 1961 are exerting an appreciable effect on mortality. There is a serious lack of representative data on rates of handicap in the survivors.
Perinatal and infant mortality rates have fallen dramatically in the developed world this century. A review of perinatal and infant mortality in Western Australia from 1970 to 1981 was undertaken, to examine trends in birthweight-specific and cause-specific rates. The predominant causes of death are now congenital malformation, stillbirth of unknown cause, preterm birth and cot death. Perinatal and infant mortality rates are unlikely to be reduced substantially until the reasons for these four causes of death are elucidated.
Perinatal and neonatal mortality rates, in the Greater Harare Maternity Unit, which showed a modest decline from 1980 to 1985, have rise dramatically since then. Half of the rise in neonatal mortality rate is due to increased numbers and an increased mortality rate in babies of birth weight less than 1001g. There is also an increase in the numbers of deaths of large babies. There is a strong case for a broad-based on-going enquiry into the reasons for such changes.
Although the infant mortality rate (IMR) has reduced by 50% during the past century, it compares poorly with the advanced countries and some developing countries. The observed fall in IMR has been mostly in post-neonatal mortality, with the result that neonatal deaths now account for over 60% of all infant deaths. The overall perinatal mortality rate (PMR) in India is still over 50 per 1000 and has shown virtually no decline during the past decade, However, PMR differs widely in different states, urban/rural areas, different hospitals and so on. PMR is seen to correlate better with social development than economic development of the representative community. The causes of perinatal deaths suggest poor health of mother and poor health facilities and are hence potentially preventable. Various studies have shown that PMR can be significantly reduced within a short span of time. The registration of vital statistics continue to be highly unsatisfactory especially in rural areas.
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Infant, neonatal and perinatal mortality rates are reliable indices of the health status and delivery of health care in a country. These rates have been declining in Singapore since World War II, and presently have become comparable to those of many developing countries. The pattern has also changed; postneonatal mortality has fallen markedly, resulting in neonatal mortality accounting for 75% of infant mortality, and first week mortality for 85% of neonatal mortality. Perinatal mortality rates have also declined over the years, due mainly to a decline in the first week mortality rates though a slight fall in stillbirth rates has also occurred. Further improvements can be expected in the perinatal and neonatal mortality rates. As neonatal intensive care improves, the prognosis of the very small and feeble infants will be brighter even though the efforts required might be very much greater. Such a challenge will prove to be very exciting and stimulating, and be an impetus to the raising of neonatal intensive care to a much higher level.
Three paediatric pathologists, one perinatal paediatrician, one obstetrician, and one epidemiologist separately used information collected on 239 babies in an attempt to validate the Wigglesworth classification of perinatal deaths. This was first done using clinical data only, then using the combination of clinical and gross necropsy findings and finally using clinical, gross necropsy, histological and any other information (for example, chromosome analyses, microbiological investigations). Only 14 (6%) of deaths changed groups within the Wigglesworth classification when gross necropsy findings were considered as well as clinical findings, and altogether only 21 (9%) changed classification when complete investigations were available. There was an unacceptable amount (15%) of disagreement between the classifiers, largely the result of failure to comply with the rules laid down for classification. We set out amendments to Wigglesworth's original definitions to clarify certain ambiguities.
CSF obtained for clinical purposes from newborn, children and adults has been analysed by high pressure liquid chromatography for hypoxanthine, xanthine, inosine, uridine and urate. Large rises in hypoxanthine and to a lesser extent xanthine occur for about 24 h after hypoxia. High concentrations were associated with later evidence of brain damage or subsequent death. Changes in CSF could be independent of those in plasma. Small or negligible rises were associated with localised and generalised infections including bacterial meningitis, fits, or both. Marked and rapid rises were found after death. These estimations may "predict" the extent of brain damage or brain death.
We analyzed retrospectively (1980-1990) the causes of death and by using a logistic regression model the perinatal and neonatal risk factors influencing the mortality in preterm infants < 34 weeks of gestation (n = 1132). When comparing the interval from 1980-1986 to 1987-1990 we observed a decreasing mortality in infants < or = 1000 g from 57% to 19% as well as in the preterm infants > 1000 g from 8.3% to 3.0% (p < 0.001). The causes of death changed considerably. During 1980-1986 fifty-two (8.2%) out of the 632 preterm infants and during 1987-1990 only seven (1.3%) out of the 600 preterm infants died in the course of a severe respiratory distress syndrome or intracranial hemorrhages. From 1980 to 1986 21% (n = 10) and from 1987 to 1990 77% (n = 10) of the neonatal deaths in preterm infants > 1000 g were attributed to lethal malformations. In those infants without lethal malformations (n = 1109) we performed a logistic regression analysis. 87 (7.8%) of these neonates died. The risk of dying was significantly higher in infants born before 1987, in male newborns and in infants suffered from a severe respiratory distress syndrome III-IV or septicemia (p < 0.0001). An increasing gestational age of one week resulted in a lowered risk of mortality (odds ratio 0.59, p < 0.0001). Adjusted for these basic variables the mortality risk was also significantly higher for birth weights < or = 1000 g, low Apgar scores, peripartal acidosis, hypothermia and intracranial hemorrhages. An intrauterine growth retardation < 10. percentile resulted in a lower mortality risk.