Per Bergsjø

Making stillbirths count, making numbers talk - Issues in data collection for stillbirths

BackgroundStillbirths need to count. They constitute the majority of the worlds perinatal deaths and yet, they are largely invisible. Simply counting stillbirths is only the first step in analysis and prevention. From a public health perspective, there is a need for information on timing and circumstances of death, associated conditions and underlying causes, and availability and quality of care. This information will guide efforts to prevent stillbirths and improve quality of care.DiscussionIn this report, we assess how different definitions and limits in registration affect data capture, and we discuss the specific challenges of stillbirth registration, with emphasis on implementation. We identify what data need to be captured, we suggest a dataset to cover core needs in registration and analysis of the different categories of stillbirths with causes and quality indicators, and we illustrate the experience in stillbirth registration from different cultural settings. Finally, we point out gaps that need attention in the International Classification of Diseases and review the qualities of alternative systems that have been tested in low- and middle-income settings.SummaryObtaining high-quality data will require consistent definitions for stillbirths, systematic population-based registration, better tools for surveys and verbal autopsies, capacity building and training in procedures to identify causes of death, locally adapted quality indicators, improved classification systems, and effective registration and reporting systems.

Anemia in pregnancy in rural Tanzania: associations with micronutrients status and infections

Objective: We studied the association between anemia in pregnancy and characteristics related to nutrition and infections.Design: Cross-sectional study.Setting: Four antenatal clinics in rural northern Tanzania.Subjects/methods: A total of 2547 women were screened for hemoglobin (Hb) and malaria plasmodia in capillary blood and for infections in urine. According to their Hb, they were assigned to one of five groups and selected accordingly, Hb<70u2005g/l (n=10), Hb=70–89u2005g/l (n=61), Hb=90–109u2005g/l (n=86), Hb=110–149u2005g/l (n=105) and Hb≥150u2005g/l (n=50). The 312 selected subjects had venous blood drawn, were interviewed, and their arm circumference was measured. The sera were analyzed for ferritin, iron, total iron binding capacity (TIBC), cobalamin, folate, vitamin A, C-reactive protein (CRP), and lactate dehydrogenase (LD). Transferrin saturation (TFsat) was calculated. Urine was examined by dipsticks for nitrite.Main outcome measures: Unadjusted and adjusted odds ratio (OR and AOR) of anemia with Hb<90u2005g/l.Results: Anemia (Hb<90u2005g/l) was associated with iron deficiency (low s-ferritin; AOR 3.4). The association with vitamin deficiencies were significant in unadjusted analysis (low s-folate; OR 3.1, low s-vitamin A; OR 2.6). Anemia was also associated with markers of infections (elevated s-CRP; AOR 3.5, urine nitrite positive; AOR 2.4) and hemolysis (elevated s-LD; AOR 10.1). A malaria positive blood slide was associated with anemia in unadjusted analysis (OR 2.7). An arm circumference less than 25u2005cm was associated with anemia (AOR 4.0). The associations with less severe anemia (Hb 90–109u2005g/l) were similar, but weaker.Conclusions: Anemia in pregnancy was associated with markers of infections and nutritional deficiencies. This should be taken into account in the management of anemia at antenatal clinics.Sponsorship: The study was supported by the Norwegian Research Council (NFR) and the Centre for International Health, University of Bergen.

Maternal HIV status and pregnancy outcomes in northeastern Tanzania: a registry-based study

Objectivesu2002 The proportion of women delivering with known HIV status in sub‐Saharan Africa is not well described. Risk of HIV transmission to newborns is a major concern, but there may also be increased risks for other adverse pregnancy outcomes.

Risk factors for Maternal Death in the Highlands of Rural Northern Tanzania: A Case-Control Study.

BackgroundTanzania has one of the highest maternal mortality ratios in sub-Saharan Africa. Due to the paucity of epidemiological information on maternal deaths, and the high maternal mortality estimates found earlier in the study area, our objective was to assess determinants of maternal deaths in a rural setting in the highlands of northern Tanzania by comparing the women dying of maternal causes with women from the same population who had attended antenatal clinics in the same time period.MethodsA case-control study was done in two administrative divisions in Mbulu and Hanang districts in rural Tanzania. Forty-five cases of maternal death were found through a comprehensive community- and health-facility based study in 1995 and 1996, while 135 antenatal attendees from four antenatal clinics in the same population, geographical area, and time-span of 1995–96 served as controls. The cases and controls were compared using multivariate logistic regression analyses. Odds ratios, with 95% confidence intervals, were used as an approximation of relative risk, and were adjusted for place of residence (ward) and age. Further adjustment was done for potentially confounding variables.ResultsAn increased risk of maternal deaths was found for women from 35–49 years versus 15–24 years (OR 4.0; 95%CI 1.5–10.6). Women from ethnic groups other than the two indigenous groups of the area had an increased risk of maternal death (OR 13.6; 95%CI 2.5–75.0). There was an increased risk when women or husbands adhered to traditional beliefs, (OR 2.1; 95%CI 1.0–4.5) and (OR 2.6; 95%CI 1.2–5.7), respectively. Women whose husbands did not have any formal education appeared to have an increased risk (OR 2.2; 95%CI 1.0–5.0).ConclusionIncreasing maternal age, ethnic and religious affiliation, and low formal education of the husbands were associated with increased risk of maternal death. Increased attention needs to be given to formal education of both men and women. In addition, education of the male decision-makers should be given high priority in the community, especially in matters concerning pregnancy and delivery preparedness, since their choice greatly affects the survival of the pregnant and delivering women.

Caesarean section among referred and self-referred birthing women: a cohort study from a tertiary hospital, northeastern Tanzania

BackgroundThe inequity in emergency obstetric care access in Tanzania is unsatisfactory. Despite an existing national obstetric referral system, many birthing women bypass referring facilities and go directly to higher-level care centres. We wanted to compare Caesarean section (CS) rates among women formally referred to a tertiary care centre versus self-referred women, and to assess the effect of referral status on adverse outcomes after CS.MethodsWe used data from 21,011 deliveries, drawn from the birth registry of a tertiary hospital in northeastern Tanzania, during 2000-07. Referral status was categorized as self-referred if the woman had bypassed or not accessed referral, or formally-referred if referred by a health worker. Because CS indications were insufficiently registered, we applied the Ten-Group Classification System to determine the CS rate by obstetric group and referral status. Associations between referral status and adverse outcomes after CS delivery were analysed using multiple regression models. Outcome measures were CS, maternal death, obstetric haemorrhage ≥ 750 mL, postpartum stay > 9 days, neonatal death, Apgar score < 7 at 5 min and neonatal ward transfer.ResultsReferral status contributed substantially to the CS rate, which was 55.0% in formally-referred and 26.9% in self-referred birthing women. In both groups, term nulliparous singleton cephalic pregnancies and women with previous scar(s) constituted two thirds of CS deliveries. Low Apgar score (adjusted OR 1.42, 95% CI 1.09-1.86) and neonatal ward transfer (adjusted OR 1.18, 95% CI 1.04-1.35) were significantly associated with formal referral. Early neonatal death rates after CS were 1.6% in babies of formally-referred versus 1.2% in babies of self-referred birthing women, a non-significant difference after adjusting for confounding factors (adjusted OR 1.37, 95% CI 0.87-2.16). Absolute neonatal death rates were > 2% after CS in breech, multiple gestation and preterm deliveries in both referral groups.ConclusionsWomen referred for delivery had higher CS rates and poorer neonatal outcomes, suggesting that the formal referral system successfully identifies high-risk birth, although low volume suggests underutilization. High absolute rates of post-CS adverse outcomes among breech, multiple gestation and preterm deliveries suggest the need to target self-referred birthing women for earlier professional intrapartum care.

Sociodemographic characteristics and perinatal mortality among singletons in North East Tanzania: a registry-based study

Objectives: Sub-Saharan Africa has the highest known perinatal mortality rates in the World, but few studies have assessed the importance of parental sociodemographic characteristics on perinatal mortality in this region. The aim of this study was to estimate how sociodemographic patterns affect perinatal mortality in Northern Tanzania. Design and settings: A registry-based study using births from 1999 to 2006 at a hospital in North Eastern Tanzania. Participants and methods: 14u2009394 singleton births with birthweight 500 g or higher and a known perinatal survival status. Births of women with residence outside the local district who were referred to the hospital for delivery for medical reasons were excluded. Results: Perinatal mortality was 41.1 per 1000 births. Factors independently associated with higher perinatal mortality were: higher paternal age (>u200a45) compared to age 26–35 (adjusted relative risk (ARR) 2.0; 95% CI 1.4 to 2.8), low paternal education (only primary) compared to secondary or higher (ARR 1.3; 95% CI 1.1 to 1.7), paternal ethnicity other than Chagga or Pare (ARR 1.4; 95% CI 1.1 to 1.7), paternal farming occupation (ARR 1.5; 95% CI 1.1 to 2.2), maternal service occupation (ARR 1.7; 95% CI 1.2 to 2.6), maternal height 150 cm or lower (ARR 1.4; 95% CI 1.0 to 1.8) and residence in the rural or semi-urban area (ARR 1.4; 95% CI 1.1 to 1.7). Conclusions: There are strong sociodemographic gradients in perinatal mortality in Africa. Paternal social characteristics appear to have stronger influence on perinatal mortality than maternal characteristics. This may reflect social and cultural conditions that need to be considered by policymakers in developing countries.

The development of perinatal audit: 20 years' experience

In the early 1950s, maternal deaths were still in the order of 1 per 1000 births and, viewed as human tragedy, a more tangible problem than death of the offspring. The Confidential enquiries into maternal deaths in England and Wales set a standard for quality assessment in the field of obstetrics. Three-yearly reports were issued regularly from 1952 onwards, and from 1985 they were extended to cover scrutiny of every maternal death in Scotland and Northern Ireland too (1). There is no doubt that these Confidential enquiries were instrumental in assuring better care and treatment, by pointing out elements of substandard care and giving advice, which was heeded. During the five decades following the first report, maternal mortality fell by nine-tenths, and most of the mothers who die in the UK (and Scandinavia) today are victims of inevitable fate, with no one to blame. Up until the end of the 1960s cesarean section in the Scandinavian countries was performed in about 2% of all births, in most cases to save or relieve the mother, while fetuses in distress were taken care of with forceps, ventouse or dexterous manipulation. If the newborn was asphyxiated, the midwife or the obstetrician took resort to gentle back-slapping, body-tilting or cold water spray, and, if unsuccessful, called on the anesthesiologist for help. Extremely preterm babies were considered nonviable and often observed without further ado. In 1967, perinatal mortality in Norway was 21 per 1000 births, when all livebirths past 16 weeks’ gestational age and stillbirths past 28 weeks were counted (2). This figure did not attract much attention at the time, although in retrospect there is good reason to believe that some of these deaths were due to substandard care.

Determinants for High Maternal Mortality in Multiethnic Populations in Western China

Our purpose of this study was to investigate determinants and patterns of associations with high maternal mortality in poor and multiethnic populations from the Xinjiang Uigur autonomous region of Western China. The researcher found that the maternal mortality ratio of Xinjiang was very high; almost half of the participants delivered at home without clean delivery, and nearly one-fifth of the participants had not received any medical treatment. Eighty-seven percent of maternal deaths were among ethnic minority groups. In multiethnic areas in Xinjiang, social–culture factors, lack of health resources, and low health services utilization were related to high maternal mortality.

Maternal smoking does not affect fetal size as measured in the mid-second trimester

Background. Cigarette smoking during pregnancy is causally related to birthweight, but we do not know whether fetal growth restriction is a continuous process or, if not, at what stage of pregnancy it affects weight gain. Material and methods. A random sample of para 1 and 2 mothers, drawn from the population of pregnant women in Bergen and Trondheim, Norway, and Uppsala, Sweden, were examined by a detailed questionnaire concerning smoking habits, menstrual history and pregnancy dating, and subjected to morphometric sonography of their fetuses in or around week 17. Of the 547 study participants, 31.9% were smokers. Gestational age was primarily determined by the last menstrual period [LMP], except in those with irregular cycles, and in 30 cases (6.6% of those with regular cycles) in whom the biparietal diameter [BPD]‐determined age deviated >14 days from the LMP‐based date. Results. The analysis did not reveal any statistically significant differences between the fetuses of non‐smokers, light smokers (0–9 cigarettes per day) and heavy (10+ cigarettes per day) smokers, regarding BPD, mean abdominal diameter [MAD] femur length [FL], and a ‘body contour index’: [BPD+FL]÷MAD. Conclusion. Tobacco‐induced fetal growth restriction probably begins after gestational week 17.

Validity of non‐invasive assessment of anaemia in pregnancy

Objectiveu2002 To test the accuracy of clinical symptoms and signs for anaemia in pregnant women, as assessed by nurse‐midwives, in two locations in Northern Tanzania.