Birth Outcomes: A Global Perspective PDF

BIRTH OUTCOMES: A GLOBAL PERSPECTIVE CHAPTER 23  BIRTH COUNTS it 28 days - death - More than 98% of neonatal mortality (death...

BIRTH OUTCOMES: A GLOBAL PERSPECTIVE CHAPTER 23  BIRTH COUNTS it 28 days - death - More than 98% of neonatal mortality (death - in - first 28 days after birth) and 3rd trimester childbirths (death of fetus in utero at >1000 grams birth weight or >28completed weeks gestation) occur in low income and middle income countries and half occur at home. In poor communities, many babies die unnamed and unrecorded For the 60 million women giving birth outside a health facility each year, physical distance is often a barrier to care seeking.  Cultural norms also keep pregnancy hidden and preclude care seeking outside the home at birth or in the post natal period, generally considered up to 6 weeks after birth. The 1% of neonatal deaths that occur in rich countries are the subject of confidential inquiries and public outcry if services are considered substandard  Birth is the time in the human life span with the greatest risk of death Each year an estimated 720,000 babies die soon after birth from a. Intra-partum related injury particularly childbirth complications b. These deaths are closely linked to at least 1.2 million stillbirths occurring during labor c. During this same period, the majority of the world’s approximately 300,000 maternal deaths occur. Therefore a total of about 2 million deaths occur at birth b 720 ON , new 300 , o mattal 1 2 milm still brut :  DEFINING BIRTH OUTCOMES A. Epidemiologic Definitions and Time Periods - Birth Outcomes include stillbirths, preterm birth and neonatal mortality - Perinatal mortality refers to death occurring before or soon after birth, including stillbirths and neonatal deaths  337mks259dey - Preterm Birth - is defined by WHO as all births before 37 weeks completed weeks of gestation, or fewer than 259 days since the first day of a woman’s menstrual period a. Extremely preterm less than 28 weeks gestation b. Very term 28 to 32 weeks gestation c. Moderate preterm 32 to < 37 completed weeks Term Birth is 37-42 weeks of gestation Post term birth 42 weeks or more of gestation STILLBIRTH – is generally defined as birth without signs of life ( no breathing, no movement, no heart rate after birth ) - Greater than 1,000 grams or greater than 28 weeks gestation to differentiate stillbirth from miscarriage. - About 80% of all stillbirths in high income countries are born preterm.  OVERVIEW OF BIRTH OUTCOMES A. Stillbirths - In 2009 the total predicted number of stillbirths was 2.6 million corresponding to a worldwide average stillbirth rate of 18.9 per 1,000 births. - In 1995, the estimated rate was 22.1 per 1,000 births - In 2009, the regions with the highest stillbirth rates were Southern Asia and sub –Saharan Africa at 26.5 and 28.4 rates per 1,000 births. - At a national level, the lowest stillbirth rates were in FINLAND and SINGAPORE at 2.0 per 1,000 births - Pakistan, Nigeria and Bangladesh had an estimated rates of over 35 per 1,000 births - Southeastern Asia is 13.9 per 1,000 births. - Developed countries is 4.6 per 1,000 births - Globally stillbirths is 18.9 per 1,000 births Intra-partum stillbirths - are generally defined as stillbirths occurring after the onset of labor, or as fresh stillbirths with skin still intact, implying death occurred less than 12 hours before birth weighing more than 1000 grams and of 28 weeks or more of gestation. - 1.2 million intra-partum stillbirths occur annually representing 1/3 of stillbirths globally. B. Preterm Births - The worldwide total estimated in 2010 was 14.9 million and a global average preterm birth rate of 11.1% - More than 1 in 10 babies worldwide is born preterm - The regions with the highest preterm birth rates in 2010 were southeastern Asia, south Asia and Sub- Saharan Africa - Preterm birth rates are highest for low income countries at 11.8%, followed by lower middle income countries at 11.3% and lowest for upper middle and high income countries at 9.3%. - In almost all high and middle income countries, preterm birth is the leading cause of neonatal and child deaths. C. Neonatal Deaths - Neonatal deaths now account for 41% of under five deaths globally. - The estimated global neonatal mortality is 23.9 per 1,000 live births - Of the 40 countries with highest neonatal mortality in 2009, only six are from outside the African continent AFGHANISTAN, Pakistan, India, Bhutan, Myanmar and Cambodia - Throughout the period 1990 – 2009, India has been the country with the largest number of neonatal deaths.  - Globally in 2010, the major causes of neonatal deaths were a. Complications from preterm births (35% ) b. Asphyxia ( 23% ) c. Infections with sepsis and pneumonia ( 27% ) - In countries with high NMR, about half of neonatal deaths result from INFECTIONS, which are generally considered preventable or treatable. - In countries with lower NMR, higher proportions of neonatal deaths are caused by preterm birth complications and congenital anomalies. - Preterm Birth Is A Risk Factor for NEONATAL and Post Neonatal Deaths - At least 50% of all neonatal deaths are preterm  ESTIMATED DISTRIBUTION OF CAUSES OF THE 3.1 MILLION NEONATAL DEATHS IN 193 COUNTRIES, 2010: 1. Preterm Birth Complications (1.08 million) 2. Intra partum Related (.72 million ) 3. Neonatal infections (.83 million ) 4. Congenital Anomalies ( 270,000 ) 5. Other Neonatal Conditions ( 181,000 )  Conditions That Affect Maternal Pregnancy Outcomes and Stillbirths / Neonatal Outcomes Mo St Neo Childbirth Complications a. Haemorrhage XX X b. Obstructed labor XX X c. Preterm labor or Birth X X  Mo St Neo Infection a. Intrauterine infection X X X b. Syphilis X X c. Malaria X X X Maternal Disorders a. Preclampsia X X X b. Diabetes X X - c. Fetal Growth Restriction - X X d. Congenital Abnormalities _ X X Importance of Maternal HEALTH and CARE - Maternal health has an important effect on birth outcomes, notably existing chronic conditions such as hypertension and diabetes. - Infections during pregnancy especially STI such as SYPHILIS, remain an important and treatable caused of stillbirths, preterm birth and growth restriction. - Maternal HIV INFECTION is also a critical factor especially in high prevalence countries. - Malaria in pregnancy is a risk factor for preterm birth, especially in areas of unstable transmission - One of the most cost effective ways to improve maternal and birth outcomes is through FAMILY PLANNING, by addressing the unmet need for modern contraceptives - UNDERNUTRITION is common among women in low income countries, and the resulting deficiencies are exacerbated in pregnancy, leading to potentially adverse effects on the mother and fetal and neonatal outcomes. - Maternal conditions related to OBESITY such as diabetes also clearly have a role for perinatal mortality especially in high income countries and are increasingly common in middle income countries.  SUMMARY OF MATERNAL RISK FACTORS FOR ADVERSE BIRTH OUTCOMES RISK FACTORS A. LIFE CYCLE FACTORS 1. Maternal Age < 18 years > 35 years 2. Maternal Size Height < 150 cm. Pre-pregnancy weight 6 Poor obstetric history RISK FACTORS B. ANTENATAL FACTORS - Multiple pregnancy - Hypertensive disorders ( pre-eclampsia, Eclampsia) - Bleeding per vagina after 8th month - Maternal jaundice - Maternal anemia - Maternal malaria (blood test positive) - Syphilis (perinatal death ) - HIV ( infant death ) RISK FACTORS C. INTRA- PARTUM FACTORS - Malpresentation (Breech ) - Obstructed labor - Prolonged second stage - Maternal fever during labor (>38 degrees centigrade) - Rupture of membranes > 24 hours - Meconium staining of liquid The odd’s ratio (OR) for ADVERSE BIRTH OUTCOMES is greatest when any of the INTRAPARTUM FACTORS is present. Two Interventions to reduce preterm birth rates in low income countries 1. Smoking cessation 2. Progesterone COMMUNITY CARE comprises promotion and implementation of healthy practices--- like - Appropriate diet - Avoidance of tobacco and indoor air pollution - Family involvement - Birth preparedness - Increasing demand for safe childbirth attended by properly trained health workers in an appropriately equipped facility and neonatal care following birth - Protocol based referral systems allow consultation or transfer of cases for appropriate clinical care to the level of comprehensive emergency obstetric and advanced neonatal care.  SUMMARY - The large numbers – more than 3 million neonatal deaths, 2.6 million third trimester stillbirths and 14.9 million preterm births – are similar to the issues considered the greatest priorities in global health today and indeed larger than some that receive major attention such ad 2 million annual HIV/AIDS death or the 800,000 annual malaria deaths. - However, neonatal deaths and particularly stillbirths, are not among global priorities - Another critical issue is the value put on baby’s life; a new born remains the most vulnerable human, and a preterm new born is even more vulnerable - Yet each loss is bereavement for families and may leave a scar than a death that is openly acknowledged and mourned. - Long term follow up studies show that 20 years after a stillbirth, a woman may remain in a delayed grief response - The societies were stillbirth and preterm birth have become priorities are those where such babies are expected to live, and women and families can express their loss - Perhaps data alone will not result in CHANGE UNTIL SOCIETY AND LEADERS RECOGNIZE THAT THESE DEATHS ARE A LOSS THAT CAN AND MUST COUNT AND BE PREVENTED. - THANK YOU-