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The term "perinatal mortality" includes deaths
that are attributed to obstetric events, such as stillbirths and
neonatal deaths in the first week of life. Perinatal mortality is an
important indicator of maternal care, health and nutrition; it also
reflects the quality of obstetric and pediatric care available. The vast
majority of global perinatal deaths occur in the low- and middle-income
countries. The perinatal mortality and stillbirth rates for India
according to National Family Health Survey-3 (2005-06) are 48.5 per 1000
live births and 19.2 per 1000 pregnancies, respectively [1].
Stillbirths include intrauterine fetal deaths which
occur prior to the onset of labor (antepartum stillbirths) as well as
those that occur during labor (intrapartum stillbirths). Antepartum
stillbirths are caused by maternal risk factors like hypertensive
disorders, placental dysfunction, hemorrhage, and fetal or placental
abnormalities, which predispose the fetus to intra-uterine hypoxia
and/or infection. In a recent meta-analysis, several interventions
showed clear evidence of impact of interventions such as heparin therapy
for certain maternal indications, syphilis screening and treatment, and
insecticide-treated bed nets for prevention of malaria, on reduction of
stillbirths [2]. Other interventions, such as management of obstetric
intrahepatic cholestasis, maternal anti-helminthic treatment, and
intermittent preventive treatment of malaria, showed promising impact on
stillbirth rates but require confirmatory studies [2]. As of now
interventions like antibiotics in prolonged premature rupture of
membranes, anti-oxidant supplementation for deficient mothers, calcium
supplementation to prevent PIH and pre-eclampsia in deficient
populations, periodontal care for mothers as well cessation of smoking
by pregnant females and reduction of exposure to smokeless tobacco have
no definite impact on reduction of stillbirth or perinatal mortality
rates. Protein-energy malnutrition and lack of peri-conceptional folic
acid, have yet not shown significant associated reductions in stillbirth
rates [2].
In this issue of Indian Pediatrics, a study
from a teaching hospital in North India evaluated the clinical,
behavioral and health-care associated risk factors of intrapartum
perinatal mortality (IPPM) [3]. They reported that a large proportion of
women deliver at home or reach health facilities late during labor. In
addition, limited round-the-clock coverage, lack of trained health care
personnel and non-adherence to standard management protocols contributed
to increased IPPM. Low socioeconomic status, absence of hemoglobin and
urine examination during pregnancy, obstructed labor, and a delay in
seeking health care were significant risk factors for intrapartum-related
perinatal mortality among emergency obstetric referrals [3]. The mode of
delivery did not affect the IPPM; previously, timely delivery, often by
caesarean section or instrumental vaginal delivery, has been shown to
reduce associated intrapartum stillbirth, and has been credited for the
relatively low intrapartum stillbirth rates in high-income countries. A
recent meta-analysis, outlined the clear advantage of strategies like
comprehensive emergency obstetric care packages, including caesarean
section in breech delivery, and induction of labor (vs expectant
treatment) in post-term pregnancy. Other advanced interventions such as
amnioinfusion and hyperoxygenation need further evidence before their
use can be advocated as a policy [5]. A number of studies have shown
that suboptimal care, particularly inadequate, inappropriate, or delayed
care of complications such as obvious fetal distress, placental
abruption, breech presentation, twin pregnancy, or eclampsia, is
associated with increased perinatal mortality [6].
While most of the success stories on reduction in
perinatal mortality are in relation to developed countries and mostly in
term babies, a lot needs to be desired in resource-poor countries where
further research is still needed to decrease the alarmingly high rates
of perinatal mortality and to define more appropriate interventions.
Competing interests: None stated; Funding:
Nil.
References
1. National Family Health Survey-3: Summary of
findings. Available from:
http://www.nfhsindia.org/NFHS-3%20Data/VOL-1/Summary%20of%20Findings%20
(6868K).pdf. Accessed on October 13, 2011.
2. Menezes EV, Yakoob MY, Soomro T, Haws RA,
Darmstadt GL, Bhutta ZA. Reducing stillbirths: prevention and management
of medical disorders and infections during pregnancy. BMC Pregnancy
Childbirth. 2009;9 (Suppl 1):S4.
3. Rani S, Chawla D, Huria A, Jain S. Risk factors
for perinatal mortality due to asphyxia among emergency obstetric
referrals in a tertiary hospital. Indian Pediatr. 2012;49:191-4.
4. Goldenberg RL, McClure EM, Bann CM. The
relationship of intrapartum and antepartum stillbirth rates to measures
of obstetric care in developed and developing countries. Acta Obstet
Gynecol Scand. 2007;86:1303-9.
5. Darmstadt GL, Yakoob MY, Haws RA, Menezes EV,
Soomro T, Bhutta ZA. Reducing stillbirths: interventions during labour.
BMC Pregnancy Childbirth. 2009;9 (Suppl 1):S6.
6. Gaffney G, Sellers S, Flavell V, Squier M, Johnson
A. Case-control study of intrapartum care, cerebral palsy, and perinatal
death. BMJ. 1994;308:743-50.
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