Reducing perinatal mortality in developing countries: high risk or improved labour management?

Abstract

This study identifies obstetric conditions related to infant mortality examines the usefulness of maternal characteristics as predictors and evaluates obstetric risk management as a viable strategy for reducing infant mortality. The study was conducted from October 1 1988 to September 30 1989 in the representative small rural community of Santa Maria de Jesus Sacatepequez Guatemala. The community was comprised of primarily Cakchiquel Maya Indians and subsistence farmers living in houses with earthen floors. Female illiteracy was 39%. Interviews were conducted among mothers in the third trimester of pregnancy. Delivery data were collected within the first week after delivery. 437 births occurred during the study year and 27 infants died (62/1000). The completed sample includes 27 child deaths and 329 pregnant mothers with surviving births. Seven (26%) deaths occurred within 24 hours of which four were due to congenital abnormalities and three were depressed at birth and died within 12 hours. The remaining 23 deaths were potentially preventable. The characteristics of the mothers with infants who died included 30% with first pregnancies 30% with over three previous pregnancies 43% with prior complications in pregnancy outcome and 70% who were illiterate. The positive predictive values for these characteristics range from 0 to 0.13%. Combining risk characteristics increases the predictive value. The strongest predictors are mother aged under 17 years with a first birth (predictive value of 0.15) mothers with over six prior pregnancies and birth intervals of under 14 months (predictive value of 0.17). 14 (61%) of the 23 deaths involved fetal malpresentation and seven were associated with complications from prolonged labor. At least 20 of the 23 potentially preventable deaths were cases where the traditional birth attendants (TBAs) should have been able to detect problems and refer mothers for medical intervention. 73% of intrapartum/one day deaths (27 infants who died) and 18% of study births involved obstetric complications. The case fatality rate is 0.35. Findings suggest better training of TBAs in detection of fetal malpresentation (location of the fetal head) and a modified risk approach and referrals. The suggestions are contingent on transportation and cultural acceptance.