Perinatal Death Surveillance and Response: A Secondary Analysis of Nepal’s Efforts

This paper presents Nepal’s experience regarding perinatal death surveillance and the country’s response in reducing preventable perinatal deaths. In developing this paper, evidence of perinatal mortality in Nepal is brought from secondary sources, mainly the assessment report of Maternal and Perinatal Death Surveillance and Response (MPDSR) system. As of 2019, this initiative has been implemented in 77 hospitals across Nepal. Challenges and barriers in implementing the MPDSR system need to be brought to attention, as the system is being scaled up to 110 hospitals. Data from the Perinatal Death Review revealed that 72% of the maternal deaths occurred during the post-partum period, due to (i) post-partum haemorrhage, (ii) hypertensive disorder, (iii) pregnancy-related infections, and (iv) non-obstetric causes. In 70% of the cases such deaths could have been prevented. Majority of perinatal deaths, at 71%, were stillbirths, mainly due to low child weight of less than 2500 grams. In conclusion, there is urgent need for the national guidelines for MPDSR system to be amended, additional and continued training provision to the health workforce, improvement in the coordination and feedback mechanism, and strengthening of the information management system. Key words: MPDSR system; Perinatal Death Review; Nepal; Perinatal Mortality; Stillbirth

Assisted Reproductive Technology and Perinatal Mortality: Selected States (2006–2011)

Objective This study aimed to compare trends and characteristics of assisted reproductive technology (ART) and non-ART perinatal deaths and to evaluate the association of perinatal mortality and method of conception (ART vs. non-ART) among ART and non-ART deliveries in Florida, Massachusetts, and Michigan from 2006 to 2011. Study Design Retrospective cohort study using linked ART surveillance and vital records data from Florida, Massachusetts, and Michigan. Results During 2006 to 2011, a total of 570 ART-conceived perinatal deaths and 25,158 non-ART conceived perinatal deaths were identified from the participating states. Overall, ART perinatal mortality rates were lower than non-ART perinatal mortality rates for both singletons (7.0/1,000 births vs. 10.2/1,000 births) and multiples (22.8/1,000 births vs. 41.2/1,000 births). At <28 weeks of gestation, the risk of perinatal death among ART singletons was significantly lower than non-ART singletons (adjusted risk ratio [aRR] = 0.46, 95% confidence interval [CI]: 0.26–0.85). Similar results were observed among multiples at <28 weeks of gestation (aRR = 0.64, 95% CI: 0.45–0.89). Conclusion Our findings suggest that ART use is associated with a decreased risk of perinatal deaths prior to 28 weeks of gestation, which may be explained by earlier detection and management of fetal and maternal conditions among ART-conceived pregnancies. These findings provide valuable information for health care providers, including infertility specialists, obstetricians, and pediatricians when counseling ART users on risk of treatment. Key Points

An Analysis of Causes and Avoidable Factors of Perinatal Deaths at Tertiary Care Hospital

Introduction: Perinatal deaths are potentially preventable and reflect the quality of care provided in the prenatal period, during labor, and to a newborn. The purpose of this study was to assess the causes and avoidable factors contributing to perinatal deaths in the year 2018-19 and compare these with the previous two years at Tertiary Care Hospital.Materials and Methods: This study was conducted from a retrospective analysis of all stillbirths and early neonatal deaths in the year July 2018 to July 2019. The Perinatal Mortality Rate, causes, and avoidable factors leading to perinatal deaths were analysed during this year and were compared with that of the previous two years at KIST Medical College and Teaching hospital.Results: PMR was 16.09 per 1000 births in the year 2018-19. Previous two studies at this hospital in the year 2017-18 and 2016-17 showed a Perinatal Mortality Rate of 14.61 and 16.27/1000 births respectively. The commonest primary cause of perinatal deaths was intrapartum hypoxia 6 (30%), preterm delivery 5 (31.25%), and congenital anomalies4 (19%) during the year 2018-19, 2017-18, and 2016-17 respectively. The most common avoidable factors identified were a maternal delay to seek health care, inadequate antenatal checkups, and inadequate antenatal counseling of danger signs by a service provider over the last three years.Conclusions: Maternal delay to seek health care and lack of maternal knowledge of danger signs during pregnancy were the common avoidable factors identified. More efforts should be made to raise awareness of pregnant women during antenatal care visits regarding early healthcare-seeking behavior when needed.

Vigilância do óbito evitável: comparação entre fetal e neonatal precoce

Comparar características sociodemográficas, assistenciais e epidemiológicas de óbitos fetais e neonatais precoces evitáveis investigados. Estudo transversal, cuja fonte de dados foi a ficha de investigação do óbito fetal, em menor de um ano, preenchida pela vigilância do Recife (PE). Procedeu-se a comparação entre os grupos de óbitos fetais e neonatais precoces evitáveis, utilizando o teste Qui-quadrado de Pearson, com a=5%. Dos 117 óbitos analisados, 94 (80,3%) eram fetais. A avaliação da assistência à saúde evidenciou falhas em 95,6% dos óbitos perinatais, destacando-se a assistência ao pré-natal, com falhas em 75,6% dos fetais e 90% nos neonatais precoces. Os óbitos reduzíveis por adequada atenção à mulher na gestação constituíram o principal grupo de evitabilidade (64,1%). Houve falhas na assistência na quase totalidade dos óbitos. A comparação entre os óbitos perinatais evitáveis permitiu avaliar a qualidade da assistência e pode contribuir com a elaboração de estratégias de redução.Descritores: Mortalidade perinatal, Saúde Materno-infantil, Estatísticas Vitais, Vigilância em Saúde Pública. Preventable death surveillance: a comparison between fetal and neonatalAbstract: To compare sociodemographic, health care and epidemiologic characteristics of investigated preventable fetal and premature neonatal deaths. Cross-sectional study, whose data source was the fetal death investigation form, in less than a year, filled out by Recife’s surveillance (PE). Then, a comparison proceeded between fetal and premature neonatal preventable death groups, utilizing the Pearson’s Chi-square test, with a=5%. From 117 analyzed deaths, 94 (80.3%) were fetal. The evaluation of healthcare presented failures in 95.6% of perinatal deaths, emphasizing the assistance to prenatal, with failures of 75.6% of fetal and 90% in premature neonatal deaths. Deaths reducible by adequate assistance for women during pregnancy were the main preventable group (64.1%). There were deficiencies in the assistance in almost all deaths. The comparison among avoidable perinatal deaths allowed the evaluation of care quality and may enable contributions towards the elaboration of reduction strategies.Descriptors: Perinatal Mortality, Maternal and Child Health, Vital Statistics, Public Health Surveillance. Vigilancia del óbito evitable: comparación entre fetal y neonatal precozResumen: Comparar características sociodemográficas, de auxílio social y epidemiológicas de óbitos fetales y neonatales precoces evitables investigados. Estudio transversal, cuya fuente de datos fue la ficha de investigación del óbito fetal, en menor de un año, rellenada por la vigilancia de Recife (PE). Se procedió a la comparación entre los grupos de óbitos fetales y neonatales precoces evitables, empleando el test Qui-cuadrado de Pearson, con a=5%. De los 117 óbitos analizados, 94 (80,3%) eran fetales. La evaluación de la asistencia a la salud denotó fallos en 95,6% de los óbitos perinatales, destacándose la asistencia prenatal con fallos en el 75,6% de los óbitos perinatales y 90% de los neonatales precoces. Los óbitos reductibles por atención adecuada a la mujer gestante constituyeron el principal grupo de evitabilidad (64,1%). Hubo fallos en la asistencia en la casi totalidad de los óbitos. La comparación entre los óbitos perinatales evitables permitió evaluar la calidad de la asistencia y puede enriquecer la elaboración de estrategias de reducción. Descriptores: Mortalidad perinatal, Salud Materno-Infantil, Estadísticas Vitales, Vigilancia en Salud Pública.

Differences in Postmortem Investigation Following Perinatal Death

Objective The study aimed to describe the postmortem investigation patterns for perinatal deaths and compare the degree of investigation between stillbirths and early neonatal deaths. Study Design We conducted a single-center retrospective review of all perinatal deaths from 2011 to 2017. Perinatal death was defined as intrauterine fetal death at ≥20 weeks' gestation, plus neonatal deaths within the first 7 days of life. Rates of postmortem investigation were compared. Results There were 97 perinatal deaths, with 54 stillbirths (56%) and 43 neonatal deaths (44%). Stillbirths were significantly more likely to receive autopsy (p = 0.013) and postmortem genetic testing (p = 0.0004) when compared with neonatal deaths. Maternal testing was also more likely in stillbirths than neonatal deaths. A total of 32 deaths (33%) had no postmortem evaluation beyond placental pathology. Conclusion Investigation following perinatal death is more likely in stillbirths than neonatal deaths. Methods to improve postmortem investigation following perinatal death are needed, particularly for neonatal deaths. Key Points

Preterm birth, stillbirth, and early neonatal mortality during the Danish COVID-19 lockdown

Importance: Using provisional or opportunistic data, three nationwide studies (The Netherlands, USA, and Denmark) have identified a reduction in preterm or extremely preterm births during periods of COVID-19 restrictions. However, these findings have been challenged as none of the studies accounted for perinatal deaths. Objective: To determine whether the reduction in extremely preterm births, observed in Denmark during the COVID-19 lockdown, could be a result of an increase in number of perinatal deaths; and to assess the impact of extended COVID-19 restrictions on the prevalence of preterm birth and perinatal death. Design: The study is a nationwide Danish register-based prevalence proportion study using detailed data to capture all births (induced abortions were excluded) throughout Denmark. We assessed the prevalence of stillbirth, preterm birth, and early neonatal death. Setting: Population-based study Participants: All singleton pregnancies delivered in Denmark, between February 27, and September 30, 2015-2020. COVID-19 lockdown was studied in 31,164 births and the extended period of COVID-19 restrictions in 214,862 births. Exposure: COVID-19 restrictions broadly (February 27, to September 30, 2020) or COVID-19 lockdown specifically (March 12, to April 14, 2020). Main Outcome: Prevalence of preterm births, stillbirths and early neonatal deaths across the periods under study. Results: The extremely preterm birth rate was reduced (OR 0.27, 95% CI 0.07 to 0.86) during the strict lockdown period, while perinatal mortality was not significantly different. During the extended period of restrictions, the extremely preterm birth rate was marginally reduced, and a significant reduction in the stillbirth rate (OR 0.69, 0.50 to 0.95) was observed. No changes in early neonatal mortality rates were found. Conclusion and Relevance: Stillbirth and extremely preterm birth rates were reduced in Denmark during the period of COVID-19 restrictions and lockdown, respectively, suggesting that aspects of these containment and control measures confer an element of protection. The present observational study does not allow for causal inference; however, the results support design of studies to ascertain whether behavioural or social changes for pregnant women may improve pregnancy outcomes.

Chlamydia pecorum detection in aborted and stillborn lambs from Western Australia

Lamb survival is an important welfare and productivity issue for sheep industries worldwide. Lower lamb survival has been reported for primiparous ewes, but the causes of this are not well studied. The aim of this study was to determine causes of perinatal deaths for lambs born to primiparous ewes in Western Australia, and identify if infectious diseases are implicated. Lamb mortality from birth to marking were determined for 11 primiparous ewe flocks on 10 farms in Western Australia. Lamb mortality from birth to marking averaged 14% for single-born and 26% for multiple-born lambs. Lamb necropsies (n = 298) identified starvation–mismosthering–exposure (34%), dystocia (24%) and stillbirth (15%) as the most common causes of perinatal lamb death. There was no evidence of exotic abortigenic pathogens in aborted and stillborn lambs (n = 35). Chlamydia pecorum was detected by qPCR in 15/35 aborted and stillborn lambs on 5/6 farms. Preliminary molecular characterisation of C. pecorum detected in samples from aborted and stillborn lambs (n = 8) using both Multilocus Sequence Typing and ompA genotyping indicated all strains were genetically identical to previously described pathogenic livestock strains, denoted ST23, and dissimilar to gastrointestinal strains. High frequency of detection of a pathogenic C. pecorum strains ST23 associated with ovine abortion and stillbirth on multiple farms located across a wide geographic area has not been previously reported. Chlamydia pecorum may contribute to reproductive wastage for primiparous sheep in Western Australia. Further investigation to understand C. pecorum epidemiology and impact on sheep reproduction is warranted.