Labour Complications Remain the Most Important Risk Factors for Perinatal Mortality in Rural Kenya

By Weiner, Renay; Ronsmans, Carine et al. | Bulletin of the World Health Organization, August 2003 | Go to article overview

Labour Complications Remain the Most Important Risk Factors for Perinatal Mortality in Rural Kenya


Weiner, Renay, Ronsmans, Carine, Dorman, Ed, Jilo, Hilton, Muhoro, Anne, Shulman, Caroline, Bulletin of the World Health Organization


Voir page 565 le resume en francais. En la pagina 565 figura un resumen en espanol.

Introduction

Perinatal mortality is an important indicator of obstetric care, health status and socio-economic development (1, 2). Perinatal mortality rates are highest in developing countries, particularly in Africa. In 1995, WHO estimated a perinatal mortality rate of 75 per 1000 births in Africa, a modest decline from the rate of 81 per 1000 births in 1983 and substantially higher than in more-developed countries, where the estimated rate was 11 per 1000 births (1).

The approach to improving maternal and perinatal health in developing countries has shifted in the last decade. In the 1980s, WHO promoted the risk approach which involved screening and risk classification of pregnancies based on maternal characteristics (3). Evidence emerged, however, that complications around the time of labour or delivery and perinatal deaths are not easily predictable, and that antenatal risk screening might be limited in its capacity to reduce maternal and perinatal mortality (4, 5). Consequently, safe motherhood programmes have focused on improving care during labour including strengthening emergency obstetric services (6). Having a health worker with midwifery skills present at delivery is now seen as one of the most critical interventions for making motherhood safer (6).

The extent to which the skilled-attendant approach will also reduce perinatal mortality is less certain. Few studies have simultaneously considered the importance of intra-partum morbidity, sociodemographic factors, and prevalent maternal illnesses such as infection with human immunodeficiency virus (HIV), malaria, and poor nutrition as risk factors for perinatal mortality. The proportion of perinatal deaths attributable to such factors also is not well known. The aim of the current study is to identify and quantify risk factors for perinatal mortality in a rural African hospital and to assess the role of labour complications in addition to sociodemographic factors and maternal illnesses such as malaria, HIV infection, anaemia and undernutrition.

Materials and methods

Study sample and population

The study population consisted of women who delivered at Kilifi district hospital, Kenya, between January 1996 and July 1997. Kilifi, situated 60 km north of Mombasa on the Kenyan coast, is a predominantly rural, farming district with a population of approximately 700 000 (7). The majority of women attend antenatal care, either at a dispensary, health centre of hospital. Less than hall of all women from this district deliver in hospital, so the women are not likely to be representative of the entire study population. Rather, they are a self-selecting group, and in this study area appear to consist of a higher proportion of the more-educated urban women and also a higher proportion of those experiencing complicated deliveries (C. Shulman, personal communication). The study sample comprised approximately 50% of deliveries at the hospital during the study period (8). Since this study was part of a larger one investigating the association between malaria, anaemia, birth-weight, pre-eclampsia and intra-uterine fetal deaths, women with any of these complications were more likely to be included (8). Women with multiple pregnancies, significant antenatal haemorrhage prior to admission, and those participating in an antimalarial intervention trial for primigravidae, on the other hand, were excluded.

Data collection

A combination of data collection methods was used: blood samples were collected on admission for the measurement of blood haemoglobin levels using a Coulter Counter and HIV antibodies using an immunoglobulin G antibody capture particle adherence test (GACPAT) (9). Placental samples were taken at delivery for histological assessment of malaria. The presence of malaria parasites in erythrocytes in the intervillous space was taken to indicate the presence of active infection and the presence of malaria pigment in fibrin, chronic or past infection (10). …

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