Roger P. Bernard

3D display of stillbirth in Indonesian obstetrics. Part 7: expansion to neonatal death.

The associations between hospital neonatal death and stillbirth birthweight and infant sex and maternal age and selected complications were analyzed for 36802 singleton-birth deliveries occurring in Indonesia in 1978-80 and displayed in 3-dimensional form. In all 3 low-birthweight categories there was an excess risk of neonatal death (31%) for boys as compared to girls. Low-birthweight males also demonstrated an excess (15%) neonatal death share of perinatal death. In terms of maternal factors the neonatal death risk was 13.0/1000 for no complications of pregnancy compared with 41.8/1000 in cases of prolonged or obstructed labor and 111.9/1000 for placenta previa with little relative variation across maternal ages. It is hypothesized that there is a link between neonatal death low-birthweight male infants and placenta previa. The precise nature of this link could constitute a focus for surveillance research with maternity care monitoring data from developing countries.

Breast-Feeding, Birth Spacing and Pregnancy Care: Prevalence and Outcome

The Maternity Care Monitoring project in Indonesia analyzes the protective triad of: 1) breastfeeding; 2) family planning; and 3) antenatal care. The same data set and the same technique of 3 dimensional display of findings is used as in previous analysis. The 11-university center pool comprises 36802 mothers with singleton birth admitted from autumn 1978 to summer 1980. 7 items were selected from the maternity record: 1) maternal education; 2) maternal age; 3) breastfeeding of the previous live birth; 4) contraceptive method used before the current conception; 5) number of antenatal visits; 6) number of months since last pregnancy ended; and 7) death of fetus/newborn. 33.2% of the mothers had breast fed 12+ months as compared with 54.9% for women for very little education in their early 30s; against only 18.2% for women with a high educational level in their early 20s. At all ages long breastfeeding (12+ months) decreases markedly with formal education and for all educational levels long breastfeeding decreases for younger age cohorts. 15.9% of the mothers had practiced family planning. Practice increases with formal education but a more marked increase in practice is documented with increasing maternal age within the educational categories. The decision to practice is more dependent on age (parity) than on formal education. The mean duration of birth interval was 31.8 months as compared with 23.5 months for women with short breastfeeding (1-5 months) and no contraception against 44.8 months for women with 6-11 months of breastfeeding and use of the IUD--a difference in length of birth interval of 21/3 months: 49.7% of the mothers showed a total lack of pregnancy care. The rate of hospital perinatal death is 76.2/1000 singleton infants. An important threshold of antenatal visits appears to be 4.

3D display of stillbirth in Indonesian obstetrics. Part 5: parity and residence versus antenatal visits.

A Quartet Control Model was used to analyze the risk of stillbirth in Indonesia by type of hospital admission antenatal visits parity and residence. The data set consisted of 36802 singleton births in university-affiliated departments of obstetrics in 1978-80. Booking and antenatal visits emerged as the strongest predictors of fetal survival. Among grandmultiparae the stillbirth risk chain ranged from a low of 13.6/1000 in booked admissions to a high of 394.8/1000 in emergency admissions. Similarly among women with no antenatal care the risk chain ranged from 24.6/1000-355.9/1000. The stillbirth risk was found to decrease sharply with increasing number of antenatal visits. In this model 27 out of 29 control categories showed a strong pregnancy care effect. The only exceptions to this effect were placenta abruptio and very low birthweight. The peak stillbirth risk pertained to emergency admissions from rural slum areas (461.5/1000). The lowest stillbirth risks recorded among booked cases from rural nonslum areas (13.1/1000) booked cases from urban slums (11.6/1000) and booked cases from urban nonslum areas (10.4/1000).

3D display of stillbirth in Indonesian obstetrics Part 8: Component analysis (intra-/antepartum)

The results of the analysis described in this article are presented in the form of 3 dimensional graphs: ante- and intra-partum deaths as a function of birth weight displayed by sex; and these death rates as a function of maternal age by type of selected complication. Incidence of stillbirths is expressed as percent of 36802 singleton births in Indonesia from 1978-1980. The most remarkable finding was that 70.7% of stillbirths were due to prolonged/obstructed labor or 102.7 deaths per 1000 women with this complication. Intrapartum death rates increase sharply with birth weight from 24.1% for very low birth weight infants to 65.5% for large infants. Advancing maternal age is also a factor. Fetal asphyxia due to passage problems is the most plausible cause. In contrast for placenta previa the intrapartum death risk increases inversely with maternal age from 75.2/100 for women over 35 to 225.4/1000 for teenagers. Both intrapartum death and antepartum death rates form a reverse J-shaped curve with highest risks for lowest birth weight flattening out to minimal risk above 2500 g. Among low birth weight infants the antepartum death rate was twice as high as that of intrapartum death. The reverse was seen in babies over 3000 g. There were no differences in risks by sex nor were there any increased risks by birth weight or maternal age among uncomplicated births.