Cases Of Perinatal Death Research Articles

How an extended perinatal audit may improve perinatal policy

Objective: A perinatal audit has the intention of quality of care improvement based on analysis of perinatal death, with our without analysis of maternal morbidity and/or mortality. Additional analysis of cases of intrapartum asphyxia could provide more insight into ways to improve quality of perinatal care.Methods: Analysis of cases of perinatal death and asphyxia in Jan Yperman Hospital, Ieper, Belgium, in 2012.Results: Three perinatal deaths occurred, none were preventable. Nineteen cases of proven metabolic acidosis have been identified. Three cases are considered possibly preventable, four cases are considered preventable. In three (possibly) preventable cases, foetal monitoring was absent during the active second stage of labour. In two preventable cases, intervention following a significant ST event in the second stage of labour was delayed. In one case intervention was delayed in the first stage of labour, while in another, indicated operative delivery in the second stage was not conducted.Conclusions: Integrating intrapartum asphyxia in the perinatal audit gives an opportunity to identify and eliminate weak points in the perinatal care chain, thereby optimizing quality of care. Lessons learned from our internal audit are the value of foetal monitoring and adequate action on significant ST events during second stage of labour.

Perinatal mortality in a rural referral hospital in the Niger Delta, Nigeria

Background: Perinatal mortality is a major public health issue in Nigeria with alarming statistics that has been given inappropriate attention both in the past and now. Materials and Methods: This is a descriptive study of all cases of perinatal deaths managed at the Baptist Medical Centre between 1 st January 1994 and 31 st December, 2003. Information was obtained from birth and labor ward registers, patients and mothers case notes and analyzed. Statistical analyses were applicable was performed with the INSTAT statistical package version 3.36 from the Statistical services center of the University of Reading. Results: There were 5,153 deliveries and 485 perinatal deaths. The perinatal mortality rate (PNMR) was 94.1/1000 deliveries, still birth rate was 53/1000 deliveries and early neonatal deaths was 41.1/1000 deliveries. There was a definite trend in PNMR during the 10 year study period marked by a steady increase. The highest perinatal deaths occurred in those greater than 35 years and those with parity ≥5 (14.1%). There were more significant perinatal deaths among the unbooked (22.4%) and this was statistically significant ( P Conclusion: PNMR of 94.1/1000 was very high in this study. There was no change in the PNMR when this study period was compared to current findings in other centers. Unbooked status was a significant risk factor for perinatal mortality. The common causes of perinatal mortality were prematurity/LBW, multiple pregnancy, severe birth asphyxia, prolonged obstructed labor and severe pre-eclampsia/eclampsia. Government and all stake holders in health care delivery should ensure the provision of emergency obstetric care for all women at all levels to reduce perinatal deaths. Interventions should be aimed at preventing, antenatal, intrapartum and postpartum complications of babies.

Retrospective Study of Seven Cases with Acute Fatty Liver of Pregnancy

Objectives. Our aim is to explore the clinical outcome of patients with acute fatty liver of pregnancy (AFLP), and evaluate the effect of early diagnosis and treatment. Methods. Seven patients who were diagnosed with AFLP were retrospectively analyzed from February 2005 to January 2013. The clinical records of the patients with AFLP were reviewed for clinical features, laboratory examinations, and maternal and perinatal prognosis. Routine laboratory evaluation revealed hyperbilirubinemia, moderately elevated liver transaminase, but negative serum hepatitis virus in each patient. For additional evidence, 126 cases of AFLP were reviewed retrospectively from original articles researched in A Medline-based English and Chinese Knowledge Infrastructure between the same periods. Results. The initial symptoms of all the 7 cases with AFLP were gastrointestinal symptoms; anorexia, nausea, vomiting, and progressive jaundice. Complications revealed with renal insufficiency in all 7 patients. Hepatic failure, MODS, hypoglycemia and DIC were seen in 4 patients (57.1%). Hemorrhagic shock, ARDS, and hepatic encephalopathy were seen in 3 patients (42.8%). There was only one case of maternal death (14.2%), three cases of perinatal death (30%) and one postnatal death (10%). Conclusion. AFLP occurs in late pregnancy is a rare clinical syndrome occurs at about 36 weeks of gestation. Early diagnosis and prompt termination of pregnancy is the key of management with multidisciplinary collaboration, comprehensive treatment and effective prevention are helpful to improve prognosis of the cases with AFLP and perinatal death.

Neuronal nuclear antigen (NeuN): A useful marker of neuronal immaturity in sudden unexplained perinatal death

IntroductionIn the developing brain neuronal differentiation is associated with permanent exit from the mitotic cycle. Neuronal nuclear antigen (NeuN) is a nuclear protein widely expressed in the mature postmitotic neurons. MethodsWe applied NeuN immunocytochemistry in 65 cases of perinatal death (16 victims of sudden intrauterine unexplained death syndrome/SIUDS, 19 of sudden infant death syndrome/SIDS and 30 controls) to test the physiological status of the brain neurons. In addition we applied both TUNEL and Caspase 3 immunohistochemical methods in order to highlight a possible relation between decreased NeuN expression and apoptotic outcome. We also attempted to see whether or not NeuN pathological changes can be related to cigarette smoke absorption in pregnancy. ResultsNeuN staining was considerably reduced or lost in SIUDS/SIDS compared to controls. However neurons with decreased NeuN-labeling showed no sign of apoptosis. A significant association was found between NeuN depletion and maternal smoking. ConclusionAltered NeuN expression can be a marker of immature and/or suffering neurons. The exclusive presence of this pattern of expression in SIUDS/SIDS victims, leads us to recommend the NeuN immunohistochemistry as a routine method in neuropathological protocols to convalidate a diagnosis of sudden perinatal death.

The Prevention, Diagnosis and Treatment of Premature Labor

The percentage of preterm births in Germany is high at 9%, but stable. 77% of cases of perinatal death are in prematurely born infants. Intensive research efforts are being directed toward the development of new means of primary and secondary prevention, diagnostic assessment, and pharmacotherapy of premature labor. We review pertinent publications that were retrieved by a selective search of the literature from 1966 to 2012, including current meta-analyses from the Cochrane database and the guidelines of German and foreign obstetric societies. Preterm labor is a multifactorial problem. The current treatment options are symptomatic, rather than causally directed. Preventive treatment with progesterone can lower the rate of preterm birth in high-risk groups by more than 30%. Transporting the pregnant women to an appropriately qualified perinatal care center and induction of fetal lung maturation lowers perinatal mortality. A variety of tocolytic drugs with different mechanisms of action (betamimetics, oxytocin antagonists, calcium-channel blockers, NO donors, and inhibitors of prostaglandin synthesis) can be used for individualized tocolytic treatment. Premature rupture of the membranes is an indication for antibiotics. The goal of all attempts to prevent and treat preterm labor is to improve preterm infants' chances of surviving with as few complications as possible. The methods discussed here can be used to prolong pregnancies at risk for preterm labor and so to reduce perinatal morbidity and mortality.

Pregnancy and Perinatal Outcomes Associated with Acinetobacter baumannii Infection

Objective To determine perinatal and pregnancy outcomes of Acinetobacter baumannii infection using clinicopathologic material from pregnant women, neonates, and perinatal postmortem examinations with positive cultures.Study Design This is a retrospective record review with placental and postmortem examination.Results During a 5-year period, 40 positive cultures were found. Three pregnancies with positive cultures close in the peripartum period were all associated with adverse outcomes including spontaneous abortion, preterm labor, and one full-term birth with histological chorioamnionitis. Two positive cultures were found in preterm neonates in the neonatal intensive care unit. Two of three cases of perinatal death grew pure cultures from blood and/or fetal tissue with placental or fetal examination demonstrating evidence of infection/inflammation with fetal inflammatory response.Conclusion This is the first case series report of A. baumannii-positive cultures in maternal, fetal, and neonatal specimen, with histopathologic evidence of infection. The results suggest a significant role of A. baumannii infection in adverse pregnancy and perinatal outcomes.

Severe acute fatty liver in pregnancy: a diagnostic dilemma in clinical practice

Background: Acute fatty liver of pregnancy (AFLP) is an uncommon complication in the third trimester of pregnancy. Differential diagnosis between severe cases of AFLP and others conditions remains challenging since there is no specific diagnostic test for this condition and the diagnosis is made by clinical and laboratory findings. Objective: To evaluate the clinical presentation, laboratory findings, and clinical outcome in patients with acute fatty liver of pregnancy.Material and Method: A retrospective study was carried out in all hospitalized pregnant patients who presented with hepatitis in the third trimester at King Chulalongkorn Memorial Hospital (KCMH), between January 2001 and March 2011. The diagnosis of AFLP had been made by clinical symptoms, laboratory evidence of acute hepatitis in the third trimester of pregnancy and by exclusion of other causes. Results: Of 102,989 deliveries, there was five AFLP, giving an incidence of 1 in 20,598 pregnancies. The mean maternal age and gestational age was 33.6 years and 36 weeks, respectively. The mean length of stay in hospital was 12 days (range 8 to 20 days). Nausea and jaundice were the most common symptoms. It is of interest that one case of AFLP coexisted with the syndrome, which is a combined medical feature of H for hemolysis, EL for elevated liver enzymes, and LP for low platelet count (HELLP). Hypoglycemia was found in all patients requiring continuous infusion of dextrose solution. Acute renal failure was also found in all cases. Initial serum creatinine varied from 1.5 to 3.7 mg/dL. None of the patients required hemodialysis and renal function returned to normal at discharge. Two cases were associated with DIC, which caused postpartum hemorrhage. Liver function tests became normal within 7 to 43 days. There was one case of perinatal death of the fetus and no maternal deaths. Conclusion: AFLP is an emergency. Multiple organ failures could develop even after delivery. In our experience, some cases of AFLP could overlap with HELLP syndrome or masquerade as TTP in the setting of pregnancy. Careful analysis of the clinical progression is important in the recognition of AFLP and prompt termination of the pregnancy is required to improve maternal and perinatal outcomes. Keywords: Acute fatty liver of pregnancy, acute renal failure, disseminated intravascular coagulopathy

Iatrogenic and spontaneous late preterm twins – which are at higher risk of neonatal complications?

To evaluate data regarding neonatal mortality and short term morbidity among iatrogenic late preterm (ILP) and spontaneous late preterm (SLP) twin births, and to estimate whether medical interventions - induction of labor in this particular context, are associated with better or poorer outcomes. Retrospective analysis of 110 late preterm dichorionic twin pregnancies was performed basing on medical charts data. All twins were delivered in years 2005-2011 at the 1st Department of Obstetrics and Gynecology Medical University of Warsaw Late preterm twins, defined as those delivered between 34 + 0-36+ 6 weeks of gestation, were divided into spontaneous and iatrogenic preterm births. The primary outcomes of the study were various neonatal adverse events, including one of the following per pregnancy: admission to Neonatal Intensive Care Unit (NICU), respiratory disorders (RD) and pneumonia, intraventricular hemorrhage (IVH), sepsis, NEC and jaundice requiring phototherapy Mann-Whitney U-test and chi-squared test were used and logistic regression performed to calculate odds ratio, with p value < 0.05 considered significant. There were 69 (62.7%) spontaneous and 41 (37.3%) iatrogenic late preterm twins. There were no differences in maternal characteristics, mode of delivery and newborns' Apgar scores. The mean birth weight did not differ significantly between the groups. There was one case of perinatal death of one twin in ILP group. Preeclampsia (31.7%) and IUGR (17%) were the most frequent indications for labor induction in ILR Women in the ILP group were administered steroid treatment for lung maturation more frequently than SLP group due to pregnancy complications (73.17% vs. 30.44%; p < 0.0001). Nevertheless, ILP twins were at higher risk of respiratory disorders (41.46% vs. 15.94%; p = 0.003--significant either with or without pneumonia) and NICU admission (31.71% vs. 14.49%; p = 0.032) than SLP twins. The only two independent factors influencing the occurrence of poor neonatal outcome were gestational age in weeks (OR 0.57; 95% Cl 0.34-0.94) and preeclampsia (OR 5.01; 95% CI 1.51-16.67). In the additional analysis of gestational age odds ratio, only the delivery at 34 weeks of gestation increased the incidence of adverse neonatal outcome almost five times (OR 4.94, 95% Cl: 1.64-14.88). The rate of cesarean delivery in the SLP was 81.61%, while in the ILP it reached 90.23% (p = 0.17). Late prematurity in twin pregnancies is associated with higher risk of neonatal morbidity than in term twins. Iatrogenic late preterm birth increases the risk of NICU admission and respiratory disorders in neonates in comparison to spontaneous late preterm birth. Despite the fact that respiratory complications are generally mild and mostly temporary there is a need for careful evaluation of indications for delivery in that particular group.

Les facteurs de risque de la mortalité périnatale dans la ville de Lubumbashi en République démocratique du Congo

BackgroundThe aim of this study is to establish factors explaining perinatal death rates in the city of Lubumbashi. MethodsWe have carried out a case controlled study in the maternity ward of Jason Sendwe hospital. Perinatal death cases have been compared to those of surviving newborn children among parturient women in the course of 2008. Sociodemographic characteristics, maternal morbidity, children's typical features, have been studied as independent variables. Their effect on perinatal mortality has been assessed using an adjusted odds ratio value at a 5% confidence interval and a logistic regression model. ResultsIn total, we considered 2279 births (mother and child pairs) for our study. Among these were 415 perinatal mortality cases and 1864 control cases. After adjustment for several parameters, household chores (AOR=1.8; 95% IC=1.2–2.9), multiple pregnancies (AOR=1.9; 95% IC=1.2–2.9), malaria (AOR=1.4; 95% IC=1.1–1.8), primiparity (AOR=1.7; 95% IC=1.3–2.4), stillbirth (AOR=5.2; 95% IC=2.5–11.0) and prematurity (AOR=2.9; 95% IC=1.5–5.5) in previous pregnancies, onset of antepartum ferver (AOR=3.0; 95% IC=1.2–7.3) and antepartum hemorrhage (AOR=6.8; 95% IC=3.1–15.0), lack of fetal motions near delivering time, dystocias (AOR=2.0; 95% IC=1.3–3.0), low birthweight (AOR=15.7; 95% IC=11.2–22.0), very low birthweight (AOR=49.0; 95% IC=28.6–85.1) and foetal macrosomia (AOR=3.5; 95% IC=1.8–7.0) were the main factors explaining perinatal mortality. ConclusionPerinatal mortality in Lubumbashi remains associated with several avoidable factors. Basic and emergency obstetrical-neonatal care (B-EMONC) should be improved. Significant efforts should be made in this direction. Perinatal audits should be established for a good heath care quality follow-up. Obstetrical care should be offered as a continuum in order to facilitate communication between the different caregivers.

Late intra-uterine death (IUD) in women with diabetes is associated with low placental weight

ObjectiveMaternal diabetes substantially increases the risk of late IUD. A greater understanding of the underlying mechanism might allow identification of pregnancies at increased risk. We have studied post-mortem reports to...

Perinatal mortality in preterm births: an analysis of causes, presence of substandard care and avoiding mortality in three Dutch regions

To analyze the causes and underlying events in cases of perinatal mortality (PNM) in preterm children. Three regions within the Netherlands. For this study, we combined data of a PNM audit over a 1-year (2003-2004) with the corresponding data of its source population (n=22,189). In the perinatal audit, all cases of perinatal death have been assessed by multi disciplinary teams of professionals in perinatal care in a consensus model for cause of death and the presence of substandard care factors (SSF). In this article, we restricted our analysis to children born between 22+0 and 37+0 weeks of pregnancy (≥154 and <259 days). We also evaluated avoidability of preterm birth and avoidability of preterm perinatal mortality (PPM) in cases with and without SSF. Of 1885 preterm children, 166 died perinatally (8.81%). The two most important determinants were small-for-gestational-age;ib47.6% of all cases with gestational age (GA) ≥25 weeks;ic and previous PNM (21.1%). In addition, PPM was substantially increased in mothers of non-Dutch origin (PPM 12.1% vs. 6.6% in children of Dutch mothers relative risk (RR)=1.88, 95% confidence interval=1.46-2.43) and in mothers in the age group 20-26 years (PPM 13.4% vs. <9% in all other categories, RR=1.69, 95% confidence interval=1.21-2.38). In 22.6% of the cases perinatal death was considered to be avoidable while in 17.0% perinatal death was related to SSF by caregivers. Immediate and appropriate actions by both caregivers and care receivers in case of early signals of possible preterm labor may reduce PNM in this category in the Netherlands by more than 20%. Improvement in surveillance of fetal growth may reduce mortality significantly in the preterm gestational period.

Non-invasive screening: The probability of events

Congenital anomalies are the cause of 20.0-25.0% of cases of perinatal death, while 3.0% of children are born with malformations of varying size. We examined the predictive values and defined the credibility ratio of the combined test results. Sensitivity of the test is 94.0%, and specificity is 99.0%. The positive likelihood ratio [likelihood ratio test (LR+)] is 94.00; a negative likelihood ratio [likelihood ratio test (LR-)] is 0.06. The pretest probability that pregnant women carry a fetus with chromosomal abnormality is 1:250. Posttest odds after the combined test to discover this abnormality are 0.3760, and probability of the same case is 0.2732 if it happens that the test result is positive. The result of our study confirms the justification of combined test usage in routine clinical practice, since the posttest odds rate in the case of a positive screening increases several times over (almost 90 times); the probability of detecting a chromosomal abnormality was about 70 times.

Perinatal Statistics of Registry Hospitals of Japan in 1974 to 1978 by The Committee on Perinatal Statistics of the Japan Society of Obstetrics and Gynecology

Annual reports of perinatal statistics in Japan from about 200 registry hospitals are summarized. A gradual decrease in the perinatal mortality rate has been observed from 16.04 in 1974 to 13.50 in 1978. Among the initially registered 129 hospitals, a similar decrease in perinatal mortality has been observed. Among the 18 main clinical causes of death, the percentages of placenta previa and neonatal respiratory distress exhibited a decrease during the last 5 years. Among the cases of perinatal death, in member hospitals of the Committee on Perinatal Statistics, three criteria were used to determine the perinatal stage for purposes of comparison, namely: 1) a gestational age of 28 or more weeks, or alternatively, birthweights of 2) 500 to 999.9 g or 3) 1000 g or more. Perinatal mortality was lowest in the group weighing 1000 g or more (9.87), slightly higher in the group aged 28 weeks or more (10.94) and highest in 500 to 999.9 g group (14.40). Individual case reports of perinatal death in member hospitals of the Committee are analyzed, and an ICD-based investigation elucidated the characteristic patterns of perinatal death.

Study on birth defects in the perinatal in Haizhu District of Guangzhou from 2004 to 2008

Objective To investigate the types and distribution of perinatal death defects in Haizhu District of Guangzhou and look for of related factors birth defects.Methods The cases of perinatal were studied from the third quarter of 2004 to the third quarter of 2008 in most of hospitals in Haizhu District.The datas were from birth defects registration cards of Maternal and Child Health Hospital of Guangdong Province,which included the perinatal birth informations of every quarters from all hospitals.Results 48248 cases of perinatal of Haizhu District were monitored in this study.There are 555 cases of perinatal death and the perinatal mortality rate was 11.5‰.There were222 cases of perinatal birth defects of all perinatal deaths and the birth defect rate of perinatal death was 36.64%.Hydrops fetalis syndrome,cleft lip and palate,hydrocephalus,congenital heart disease and limb deformities are the top five defects in a variety of cases.Conclusion Birth defects is one of the major causes of perinatal death.It is important for us to promote reproduetive health education and pre-malital medical examination,enhance environmental awareness in pre-marital health,eugenic,and maternal health,which should minimize the occurrence of birth defects. Key words: Perinatal; The death of defect; Monitoring

Value of the Combined Test in Prenatal Diagnostics

Value of the Combined Test in Prenatal DiagnosticsCongenital anomalies are the cause of 20.0-25.0% of cases of perinatal death, while 3.0% of children are born with malformations of varying size. We examined the predictive values and defined the credibility ratio of the combined test results. Of 317 examined pregnant women, 16 (5.05%) gave a pathological karyotype after amniocentesis: of these, nine (2.84%) had chromosomal number aberrations and seven (2.21%) had chromosomal structure aberrations. We determined the ultrasonographic parameters using the standards of the Fetal Medicine Foundation (location please). We measured free β-subunit of choriogronadotropin (β-HCG) and pregnancy associated plasma protein A (PAPP-A) in venous blood from pregnant women using a combined commercial assay. Sensitivity of the test is 94.0%, and specificity is 99.0%. The positive likelihood ratio [likelihood ratio test (LR+)] is 94.00, a negative likelihood ratio is [likelihood ratio test (LR-)] 0.06. The pretest probability that pregnant women carry a fetus with chromosomal abnormality is 1:250. Posttest odds after the combined test to discover this abnormality is 0.3760, and probability of the same case is 0.2732 if it happens that the test result is positive. The result of our study confirms the justification of combined test usage in routine clinical practice, since the posttest odds rate in the case of a positive screening increases several times over (almost 90 times); the probability of detecting a chromosomal abnormality was about 70 times. The combined screening test, if used methodologically correctly, has a high predictive value in detecting fetal congenital anomalies.

The Dutch Perinatal Audit Project: a feasibility study for nationwide perinatal audit in the Netherlands

To investigate the feasibility of nationwide perinatal mortality audits in the Netherlands. Over a one-year period, data for all cases of perinatal mortality were collected. Six perinatal audit panels of professionals within perinatal care investigated and classified causes of death and identified the presence of substandard care factors (SSF). Out of 22,189 newborns, 228 cases of perinatal mortality were audited. Placental pathology, congenital anomalies and preterm birth were the main causes of perinatal death. SSF by caregivers were identified in 72 cases (32 %). Almost 20% of the cases were not reported. In the Netherlands, perinatal audit is well supported by all groups of caregivers. It reveals usable facts and findings for the quality assessment of perinatal care. This audit showed that in 9% of the cases perinatal death was related to SSF and potentially avoidable. However, immediate reporting of cases of perinatal death apart from regular registration in the perinatal database proved to be inaccurate. Once a nationwide audit program is realized, in which data from the different caregivers will be collected in a single database instead of collection by linkage afterwards, this problem should be solved. Local audits will start from 2009. These audits will assess mortality cases within their respective areas and may initiate adjustments for perinatal care and optimize the quality of care and inter-professional collaboration. Yearly nationwide audits will focus on specific items (e.g. term or post-term deliveries) and may well offer an opportunity for the development or adjustment of national guidelines.

Uterine rupture in the Netherlands: a nationwide population‐based cohort study

To assess incidence of uterine rupture in scarred and unscarred uteri and its maternal and fetal complications in a nationwide design. Population-based cohort study. All 98 maternity units in The Netherlands. All women delivering in The Netherlands between August 2004 and August 2006 (n = 371,021). Women with uterine rupture were prospectively collected using a web-based notification system. Data from all pregnant women in The Netherlands during the study period were obtained from Dutch population-based registers. Results were stratified by uterine scar. Population-based incidences, severe maternal and neonatal morbidity and mortality, relative and absolute risk estimates. There were 210 cases of uterine rupture (5.9 per 10,000 pregnancies). Of these women, 183 (87.1%) had a uterine scar, incidences being 5.1 and 0.8 per 10,000 in women with and without uterine scar. No maternal deaths and 18 cases of perinatal death (8.7%) occurred. The overall absolute risk of uterine rupture was 1 in 1709. In univariate analysis, women with a prior caesarean, epidural anaesthesia, induction of labour (irrespective of agents used), pre- or post-term pregnancy, overweight, non-Western ethnic background and advanced age had an elevated risk of uterine rupture. The overall relative risk of induction of labour was 3.6 (95% confidence interval 2.7-4.8). The population-based incidence of uterine rupture in The Netherlands is comparable with other Western countries. Although much attention is paid to scar rupture associated with uterotonic agents, 13% of ruptures occurred in unscarred uteri and 72% occurred during spontaneous labour.

Risk Factors For Perinatal Mortality In Arua Regional Referral Hospital, West Nile, Uganda

In low-income countries, the majority of neonatal deaths occur during the perinatal period. The fourth millennium development goal of reducing child mortality cannot therefore be met without substantial reduction in perinatal deaths. To investigate the risk factors for perinatal mortality in Arua regional referral hospital, West Nile region. We conducted a facility based unmatched case-control study at Arua Regional Referral hospital during January- March 2006. A total of 60 new cases of perinatal deaths and 120 controls were selected over a 3 months period. A case was defined as any baby born after 28 weeks of gestation either as a still birth or born alive but died within 7 days post delivery. A control was any baby born after 28 weeks of gestation and survived the first seven days of life. Control mothers were followed at home after one week to check if any perinatal death occurred. Logistic regression analysis was used to determine the risk factors for perinatal mortality. The mean age of case mothers was similar to that of controls 24.1 years, range 15-38 years versus 24.9 years range 16-40 years (p - value = 0.52). Babies who died during the perinatal period were more likely not to have been resuscitated (OR = 24.85, 95% CI 8.77-74.17). Mothers whose babies died were more likely to have travelled more than 5 kilometres to Arua hospital (OR = 3.89 CI 1.96-7.74), having had transport problem (OR= 3.35, CI 1.00-12.00), first sought help from other health facilities or TBA (OR = 8.03, CI 3.38-19.46), have been referred due to obstetric complications (OR = 11.45, CI 4.75-27.59), and had obstetric interventions i.e. C/S or vacuum extraction (OR= 3.79, CI 1.64-8.83). After controlling for confounding, significant risk factors for perinatal deaths included living more than 5 kilometres from the hospital (Adjusted OR = 0.91, CI 0.83-0.95), transport problem (Adjusted OR = 4.37, CI 1.14-39.75), baby not being resuscitated (Adjusted OR=4.87, CI 4.371-7.11) and baby being born with low Apgar score (Adjusted OR= 6.76, CI 2.75-187.38). Our study has identified several risk factors for perinatal deaths related to poor accessibility to and low quality of health care services in the setting. The study underscores the importance of improved accessibility to and quality of basic and comprehensive emergency obstetrical care. The findings suggest the need to improve the capacity of local health system at first, second and tertiary levels, accessibility to and quality health care services in the settings.

Evaluation of forensic perinatal and neonatal autopsies in Istanbul

Autopsy findings play an important role in prevention of perinatal and neonatal deaths. Therefore, we attempted to reveal demographic and forensic features of these deaths in Turkey. We retrospectively reviewed autopsy reports for 184 cases of perinatal deaths released from Istanbul Forensic Medicine Institute Morgue between 2000 and 2002 and investigated demographic and medico-legal features of the cases. The mean age of the cases was 2.98 +/- 6.41 days. Fifteen point two percent (15.2%) of the cases were of murder, 52.7% of the cases were illegitimate children and 41.3% had the ability to survive. It can be suggested that autopsy and post-mortem examinations should be performed in order to determine the real causes and contributing factors of perinatal and neonatal deaths. Data obtained in autopsies and postmortem examinations will make great contributions to the prevention of these deaths.

Design and evaluation of a regional perinatal audit

Objective To describe the experiences of a regional audit of perinatal deaths, including the experiences of the audit members, to discuss similarities and differences with other, existing perinatal audits and to summarize the implications for future implementation. Study design Perinatal audit with blinded regional auditors. Consecutive cases of perinatal death were analysed for the presence of substandard care. A random selection of cases was reviewed by an external audit panel. The prevalence of substandard care in the Amsterdam audit was compared with other, existing audits. A survey among audit members was executed. Results Care providers from all Amsterdam hospitals, as well as general practitioners and independent midwives cooperated. One hundred thirty-seven perinatal deaths were reviewed. In 25% of all perinatal death cases, substandard care factors were present. After 23 completed weeks substandard care factors were present in 35% of cases, and in 52% of intrapartum deaths. These figures are comparable with other, non-regional oriented audits. The review of the external panel was also comparable to the review of the regional audit committee. All audit members felt secure to discuss freely the presence of substandard care. Conclusion First systematic experiences with a regional perinatal audit are described. We conclude that a regional perinatal audit is executable. Cooperation of regional care providers is good. Review of substandard care factors is comparable to other, non-regional oriented perinatal audits.