Neonatal and Birth Outcomes Quiz

Birth Outcomes: A Global Perspective

• Neonatal mortality (death in first 28 days after birth) and third-trimester childbirths (death of a fetus in utero weighing over 1000 grams or after 28 completed weeks of gestation) are overwhelmingly prevalent in low- and middle-income countries.
• Half of these deaths occur at home.
• Many babies in impoverished communities are unnamed and unrecorded.
• Distance from healthcare facilities often hinders access to care for women giving birth outside of these facilities (60 million annually).
• Cultural norms frequently conceal pregnancies and discourage care-seeking outside the home, especially during and after childbirth (up to 6 weeks postpartum).
• In wealthy countries, the death of a newborn is highly scrutinized and considered a critical failing if healthcare services are inadequately provided.
• Birth is the period of life with the highest risk of death.
• An estimated 720,000 babies die soon after birth. This relates significantly to intrapartum-related complications and at least 1.2 million stillbirths from complications during labor.
• Maternal deaths and neonatal deaths combined amount to approximately 2 million deaths at birth.
• Perinatal mortality includes deaths that occur before or soon after birth, including stillbirths and neonatal deaths.
• Epidemiological definitions often include stillbirths, preterm birth, and neonatal mortality, when defining birth outcomes.

Defining Birth Outcomes

• Birth Outcomes: Stillbirths, preterm birth, and neonatal mortality.
• Perinatal mortality: Death occurring before or soon after birth, including stillbirths and neonatal deaths.

Preterm Birth

• WHO defines preterm birth as birth before 37 completed weeks of gestation, or fewer than 259 days since the first day of a woman's last menstrual period.
• Subcategories of preterm birth:
  • Extremely preterm: less than 28 weeks gestation
  • Very preterm: 28 to 32 weeks gestation
  • Moderate preterm: 32 to <37 completed weeks gestation

Stillbirth

• Stillbirth is defined as birth without signs of life.
• A baby weighing over 1000 grams or greater than 28 weeks of gestation is considered a stillbirth and not a miscarriage (differentiation).
• Approximately 80% of stillbirths in high-income nations are reported to occur prematurely.

Overview of Birth Outcomes - Stillbirths

• In 2009, the predicted number of stillbirths globally was 2.6 million, translating to a worldwide average rate of 18.9 per 1,000 births.
• In 1995, the estimated worldwide average rate of stillbirths was 22.1 per 1,000 births.
• Southern Asia and sub-Saharan Africa had the highest stillbirth rates in 2009 (26.5 and 28.4 per 1,000 births, respectively).
• Finland and Singapore had the lowest stillbirth rates, at 2.0 per 1,000 births.
• Pakistan, Nigeria, and Bangladesh had exceptionally high rates (above 35 per 1,000).

Intra-Partum Stillbirths

• Intra-partum stillbirths commonly refer to stillbirths occurring after the onset of labor, or as fresh stillbirths with intact skin, indicating death less than 12 hours before birth, and weighing over 1000 grams, and at least 28 weeks gestation.
• The annual count of intra-partum stillbirths is estimated at 1.2 million (one-third of all stillbirths globally).

Preterm Births - Overview

• The estimated total of preterm births for 2010 was 14.9 million, correlating to an average rate of 11.1% globally.
• Southeast Asia, South Asia, and Sub-Saharan Africa had the highest preterm birth rates in 2010.
• Preterm birth rates are significantly higher in low-income countries (11.8%), followed by lower-middle-income countries (11.3%), and are lowest in upper-middle and high-income countries (9.3%).

Neonatal Deaths

• Neonatal deaths now represent 41% of under-five deaths globally.
• Estimated global neonatal mortality is 23.9 per 1,000 live births.
• Out of 40 countries with the highest neonatal mortality in 2009, only six were outside of the African continent (Afghanistan, Pakistan, India, Bhutan, Myanmar, and Cambodia).
• India had the highest number of neonatal deaths between 1990 and 2009.
• Major causes of neonatal deaths (globally in 2010):
  • Complications from preterm birth (35%)
  • Asphyxia (23%)
  • Infections (sepsis and pneumonia) (27%)

Preterm Birth as a Risk Factor

• Preterm birth is a significant risk factor for neonatal and post-neonatal deaths, with at least 50% being preterm-related.
• Estimated distribution of causes of 3.1 million neonatal deaths in 193 countries in 2010
  • Preterm birth complications (1.08 million)
  • Intrapartum related (0.72 million)
  • Neonatal infections (0.83 million)
  • Congenital anomalies (270,000)
  • Other neonatal conditions (181,000)

Maternal Health and Care

• Maternal health significantly influences birth outcomes, particularly chronic conditions like hypertension and diabetes.
• Infections during pregnancy, especially STIs like syphilis, remain linked to stillbirths, preterm birth, and growth restriction.
• HIV and malaria in pregnancy are critical risk factors, notably in high-prevalence regions and areas with unstable transmission.
• Improving maternal and birth outcomes is closely associated with effective family planning, adequately addressing unmet needs for modern contraceptives.
• Undernutrition in low-income nations is a significant concern, exacerbating pregnancy deficiencies and negatively impacting maternal and neonatal health. Maternal conditions related to obesity, like diabetes, are also major risk factors, particularly in high-income nations.

Risk Factors for Adverse Birth Outcomes

• Life Cycle Factors:
  • Maternal age (<18 or >35 years)
  • Maternal size (height < 150 cm, pre-pregnancy weight <47 kg)
  • Parity (especially primigravida, and parity >6)
  • Obstetric history (poor)
• Antenatal Factors:
  • Multiple pregnancy
  • Hypertensive disorders (pre-eclampsia, eclampsia)
  • Bleeding per vagina after 8th month
  • Maternal jaundice
  • Maternal anemia
  • Maternal malaria (positive blood test)
  • Syphilis (perinatal death)
  • HIV (infant death)
• Intrapartum Factors:
  • Malpresentation (breech)
  • Obstructed labor
  • Prolonged second stage
  • Maternal fever during labor (>38 degrees centigrade)
  • Rupture of membranes > 24 hours
  • Meconium staining of liquid

Interventions

• Smoking cessation and progesterone are identified as potential interventions to reduce preterm birth rates in low-income countries.

Community Care

• Community care focuses on promoting healthy practices (diet, avoiding tobacco and indoor air pollution, family involvement).
• Encouraging demand for safe childbirth, emphasizing properly trained healthcare workers and appropriately equipped facilities.
• Protocol-based referral systems for cases needing advanced obstetric and neonatal care.

Summary

• High neonatal death rates (over 3 million), stillbirths (2.6 million), and preterm births (14.9 million), are major global health concerns.
• Despite these alarming numbers, issues like these are not always prioritized as global health emergencies, and often overshadowed by other serious issues like HIV and malaria.
• A critical aspect is the value and vulnerability associated with babies, especially preterm babies, and often this is not recognized in the immediate aftermath of the loss of a child.
• Data recognition may not immediately translate to improved outcomes unless communities and leaders realize the need to address these issues.