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Changing trends in perinatal deaths at the Armed Forces Hospital, Riyadh,

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Journal of Obstetrics and Gynaecology (2 00 1 ) Vol. 2 1 , No. 1, 4 9 - 5 5
OBSTETRICS
Changing trends in perinatal deaths at the Armed
Forces Hospital, Riyadh, Saudi Arabia
R. A. MESLEH, A. M. KURDI, T. O. SABAGH and A. A. ALGWISER
Department of Obstetrics and Gynecology, Armed Forces Hospital, Riyadh, Saudi Arabia
Summary
A total of 104 522 babies were delivered at the Riyadh Armed
Forces Hospital between 1979 and 1998, including 807 still-
births and 658 neonatal deaths. The 20-year period was divided
into four 5-yearly intervals for comparative purposes. The over-
all Perinatal Mortality Rate (PMR) for infants weighing 500
grams or more ranged between 20·2 per 1000 in 1979 and 13 per
1000 in 1998. The lowest PMR of 10·3 per 1000 was recorded
in 1985. Thirty-one per cent of the perinatal deaths were
unbooked. The corrected neonatal death rate (excluding congeni-
tal anomalies) dropped from 10·1 per 1000 in 1979 to 1·7 per
1000 live births in 1998 – The corrected stillbirth rate dropped
from 12·1 per 1000 births in 1979 to six per 1000 in 1998. Of
the 807 stillbirths, 24·1% had lethal congenital anomalies while
29·5% were unexplained, 4% had hydrops fetalis, 2% died as a
consequence of toxaemia of pregnanc y, 7·5% were associated
with antepartum haemorrhage, 7·9% were mechanical, related to
cord accident and ruptured uterus, 9.8% died as a consequence
of maternal disease, 5·4% of intrapartum asphyxia and 6·4% pla-
cental insufficiency. Of the 658 neonatal deaths, 47·5% had lethal
congenital anomalies, 2% had hydrops fetalis, 7·6% died as a re-
sult of intrapartum asphyxia, 38% died as a result of prematurity
with its complications of severe respiratory dysfunction and
intraventriculor and pulmonary haemorrhage, 4·1% died in
NICU of secondary infection and 0·7% were unclassified. The
overall PMR for infants weighing 500 grams or more was 14·1
per thousand. Congenital anomalies and low birth weight/prema-
turity accounted for 85·5% of the neonatal deaths. Congenital
anomalies and unexplained deaths accounted for 53% of total
stillbirths while maternal disease was responsible for 9·8% of
total stillbirths. Reducing congenital anomalies and preventing
prematurity and provision of good antenatal care will help in re-
ducing PMR still further.
Introduction
The reproductive pattern in Saudi Arabia is character-
ised by pregnancies starting at an early age, by high
fertility throughout the reproductive span, by low edu-
cational attainment of the mother and by poor coverage
by antenatal services (Hashim and Anokute, 1994).
Perinatal mortality is a good indicator of the quality
of perinatal health care. Maternity services have shown
a considerable improvement over the last 20 years.
National statistics on perinatal mortality are limited (AI
Faraidy et al., 1993). The most complete and officially
reliable national statistical publication for Saudi Arabia
comes from the Ministry of Health. The perinatal mor-
tality rate for the Kingdom of Saudi Arabia declined
from 25·6 per 1000 in 1981 to 16 per 1000 in 1989
(Hashim and Anokute, 1994).
The aim of this study was to show the changing
Correspondence to: R. A. Mesleh FRCOG, C124 Armed Forces Hospital, Riyadh, PO Box 7897, Riyadh 11159, Saudi Arabia.
Tel: + 966 1 4777714 ext. 5461; Fax: + 966 1 4760853 .
ISSN 0 1 4 4 - 3 6 1 5 print/ISSN 1 3 6 4 - 6 8 9 3 online/0 1 /0 1 0 0 4 9 - 0 7 ã
DOI: 1 0 .1 0 8 0 /0 1 4 4 3 6 1 0 0 2 0 0 2 2 1 2 2
trends in perinatal deaths at the RAFH over the last
20 years (1979–1998), define causes, outline meas-
ures of prevention and define areas of improvements.
Material and methods
The Armed Forces Hospital, Riyadh (RAFH) is a ter-
tiary care hospital which was opened late in 1978. It
cares for all employees of the armed forces, military
and civilian and their families. Perinatal mortality meet-
ings are held monthly and prenatal review meetings are
held bi-monthly to discuss all cases of congenitally
malformed babies discovered at routine ultrasound
scanning. Malformations, which are considered incom-
patible with life, were marked not to carry out
caesarean section for a fetal indication.
This was a retrospective case record analysis of all
reported stillbirths and neonatal deaths of babies de-
livered at Riyadh Armed Forces Hospital (RAFH) and
weighing 500 grams or more. A stillbirth was defined
as a baby delivered weighing 500 grams or more with
no signs of life. Birth weight was taken into consid-
eration as this is more accurate than gestational age,
especially in a society where a considerable number
of patients are unaware of their last menstrual period
or conceived during a period of lactational amenor-
rhoea. Early neonatal death was defined as death of
an infant during the first week of life, who was born
alive, weighing 500 grams or over. The deaths were
classified according to the cause of death as speci-
fied and agreed upon at the departmental perinatal
mortality meeting. When more than one cause may
have contributed to the death of that baby, the most
likely primary cause was recorded. An attempt was
made to correlate the cause of death to the predispos-
ing antenatal, intrapartum or postpartum cause. The
effect of antenatal care, method of delivery and birth
weight were analysed. To make these data meaning-
ful, we classified the period of study into 5-yearly
intervals. Babies weighing less than 500 grams or de-
livered outside this hospital and who died in neonatal
intensive care unit were excluded from the study. c 2
was used for statistical analysis and P value < 0·05
was considered statistically significant.
Results
The total annual deliveries have increased from 1377
in 1979 to 6988 in 1998. Table I shows a compara-
Taylor & Francis Limited, 2 0 0 1
 50
R. A. Mesleh et al.

Table I. Comparative table for 20 years (Riyadh Armed Forces Hospital 1979- 1998)

Years 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1994 1996 1997 1998 Total

Total infants
delivered 1396 202 2 2416 336 1 361 5 4001 4440 5128 5074 5416 5861 6346 463 3 691 6 7015 708 2 733 1 7801 7680 69881 04 522
Perinatal deaths 36 52 43 70 58 44 54 65 67 66 87 81 58 103 100 86 105 95 104 91 1465
Perinatal mortality
rate 2 5 ·8 25 · 7 1 7 ·8 20 · 8 16 1 3 ·2 1 0 ·3 1 2 ·6 13 14 14 · 3 13 · 8 12 · 1 14 · 9 15 12 · 5 1 4 ·2 12 13 ·4 13 1 4 ·1
Total stillbirths 18 22 15 39 38 26 27 29 33 39 43 47 35 45 62 43 51 63 64 68 807
Congenital anomalies 1 3 1 8 6 2 5 6 7 7 7 13 10 12 22 13 14 17 15 26 195
Stillbirth rate 1 2 ·9 10 · 9 6 ·2 11 · 6 10 · 5 6 ·5 6 ·1 5 ·7 6 ·5 7 ·2 7· 3 7· 4 7· 6 6· 5 8· 8 6· 1 7 8· 1 8·3 9·7 7 ·7
Corrected stillbirth
rate excluding
congenital
anomalies 1 2 ·1 9· 4 5 ·8 9· 2 8· 8 6 4 ·9 4 ·5 5 ·1 5 ·9 6· 1 5· 3 3· 8 4· 8 5· 7 4· 2 5 5· 9 6·4 6 5 ·8
Neonatal deaths 18 30 28 31 20 18 27 36 34 27 44 34 23 58 38 43 54 32 40 23 658
Congenital anomalies 4 12 7 18 12 12 11 21 18 11 19 6 15 25 18 19 30 17 27 11 313
Early neonatal
death rate 13 1 5 1 1 ·6 9· 3 5· 6 4 ·5 6 ·1 7 6 ·7 5 7· 5 5· 4 5 8· 4 5· 4 6· 1 7 ·4 4· 1 5·2 3·3 6 ·3
Corrected neonatal
death rate excluding
congenital
anomalies 1 0 ·1 9 8 ·7 3· 9 2· 2 1 ·5 3 ·6 2 ·9 3 ·1 2 ·9 4· 3 4· 4 1· 7 4· 8 2· 8 3· 4 3 ·3 1· 9 1·7 1·7 3 ·3
 Changing trends in perinatal deaths, Saudi Arabia 51

Table II. Comparative table, Armed Forces Hospital, Riyadh, 1979- 1998

Years 1979- 1983 1984- 1988 1989- 1993 1994- 1998 Total

Total infants delivered 12 8 10 24 0 59 30 7 71 36 882 104 522

Perinatal deaths 259 296 429 481 1465
Perinatal mortality rate (PMR) 20 ·2 12 ·3 13 ·9 1 3 ·0 1 4 ·1
Corrected (PMR) excluding congenital anomalies 14 ·6 8·1 9·1 7 ·9 9 ·1
Total stillbirths 132 154 232 289 807
Congenital anomalies 19 27 64 85 195
Stillbirth rate 10 ·3 6·4 7·5 7 ·8 7 ·7
Corrected stillbirth rate excluding
congenit al anomalies 8·8 5·3 5·4 5 ·5 5 ·8
Neonatal deaths 127 142 197 192 658
Congenital anomalies 53 73 83 104 313
Early neonatal death rate 10 ·0 5·9 6·4 5 ·2 6 ·3
Corrected neonatal death rate excluding
congenit al anomalies 5·8 2·9 3·7 2 ·4 3 ·3

tive table. A total of 104 522 babies were delivered at
this hospital during the last 20 years. During the same
period, there were 1117 sets of twins, 42 sets of tri-
plets, six sets of quadruplets and one conjoined twin.
Eight hundred and seven babies were born dead and
658 died during the first week of life. The overall peri-
natal mortality rate (PMR) ranged between 25·8 and
10·3 per 1000 births (Figure 1). The corrected PMR
dropped from 14·6 per 1000 in the first period to 7·9
per 1000 in the fourth period (Table II). Thirty-one
per cent of the perinatal deaths were unbooked and
received no antenatal care.
Neonatal deaths
Of the 103 715 live-born babies, 658 died during the
first week of life. The early neonatal death rate was
6·3 per 1000. The corrected neonatal death rate
dropped from 5·8 per 1000 in the first period to 2·4
per 1000 in the last period (Table II).
Congenital anomalies. Of these 658 early neonatal
deaths, 313 (47·5%) babies had lethal congenital
anomalies (Table III). Of the 313 congenitally
malformed babies, 47 (15%) had neural tube defect, 37
(11·8%) had congenital heart disease, 77 (24·6%) had
multiple anomalies and 26 (8·3%) had Potter’s syndrome
(Table IV). The trend of congenital anomalies as a cause
of neonatal deaths remained constant ranging between
42 and 54% of total neonatal deaths.
Birth asphyxia. Of the 50 (7.6%) babies who died as
a result of birth asphyxia (Table II), the final method
of delivery was caesarean section (CS) in 24, forceps/
ventouse in four, assisted breech delivery in seven and
normal delivery in 15. The indications for CS were:
cord prolapse three, fetal distress 13, antepartum
haemorrhage six and fetal distress in second twin two.
Birth asphyxia as a cause of neonatal deaths showed
a steady decline from 12·6% in first period to 2% in
the fourth 5-year period.
Prematurity. Two hundred and fifty (38%) babies died
as a result of extreme prematurity with its associated
morbidity. Of the 250 premature babies, 168 (67%)
weighed below 1000 grams. All babies died as a result
of known associated complications of extreme
prematurity (hyaline membrane disease with severe
respiratory dysfunction, intraventricular and pulmonary
haemorrhage). Prematurity as a cause of neonatal
deaths ranged between 27·4 and 42·5% of the total
neonatal deaths. Congenital anomalies and prematurity
together accounted for 85·5% of total neonatal deaths.
Neonatal infection. Neonatal infection was responsible
for 27 (4·1%) neonatal deaths.
Stillbirths
Of the 105 422 infants delivered, 807 were stillborn.
This gave an overall stillbirth rate of 7·7 per thousand
births. The corrected stillbirth rate dropped from 8·8
per 1000 in the first period to 5·5 per 1000 in the fourth
one (Table II).
Congenital anomalies. These accounted for 24·1% of
the total stillbirths (Table V). Of the 195 stillbirths who
had lethal congenital anomalies, 71 (8·8%) babies had
multiple congenital anomalies, 53 (6·5%) had neural
tube defect, 15 (1·8%) had congenital heart disease
and 25 (3%) babies had severe hydrocephaly (Table
VI). Congenital anomalies as a cause of stillbirth
showed a steady rise from 14·4% in the first 5-year
period to 29·4% in the fourth 5-year period (Table V).

Hydrops fetalis. Thirty-three babies (4%) died as a

Figure 1. Perinatal mortality rate, Riyadh Armed Forces
Hospital (1979–1998).
result of hydrops fetalis. In eight cases it was
secondary to rhesus incompatibility and 25 were
secondary to non-immune hydrops fetalis. Apart from
the first 5-year period which had only one stillbirth due
to hydrops fetalis, the percentag e of hydropic babies
ranged between 4 and 5.2% of total stillbirths.
52 R. A. Mesleh et al.

Table III. Causes of neonatal deaths

Years 1979- 1983 198 4- 19 88 198 9- 19 93 1994- 1998 Grand total P

1. Congenital anomaly 53 (41·7% ) 73 (51·4% ) 83 (42·0% )104 (54·0% ) 31 3 (47·5% )< 0·001
Neural tube defect 3 12 17 15 47
Others 50 61 66 89 266

2. Hydrops fetalis 0 (0·0% ) 3 (2·1% ) 6 (3·0% ) 4 (2·0% ) 13 (2·0 % ) NS

Immune 0 2 3 1 6
Non-immune 0 1 3 3 7

3. Asphyxi: intrapartum 16 (1 2·6% ) 14 (9·8% ) 16 (8·1% ) 4 (2·0% ) 50 (7·6 % )< 0·0 01

Mode Caesarean 6 8 8 2 24
of Forceps/Ventouse 3 0 0 1 4
delivery Breech 2 1 4 0 7
Normal 5 5 4 1 15

4. Prematurity 54 (42·5% ) 39 (27·4% ) 86 (43·6% ) 71 (37·0% ) 25 0 (38·0% )< 0·001

1 00 0 ±g 22 23 63 60 168
Birth 1 0 0 0- 1 4 9 9 ±g 25 13 19 10 67
weight 1 5 0 0- 1 9 9 9 ±g 7 3 4 1 15

HMD 49 28 45 57 179
Cause of HMD+ IVH 4 10 33 14 61
death Pulmonary haemorrhage 1 1 8 0 10

5. Infection 3 (2·3% ) 9 (6·3% ) 6 (3·0% ) 9 (4·7% ) 27 (4·1 % ) NS

Necrotising enterocolitis 3 0 0 0 3
Septicaemia 0 9 6 9 24

6. Unclassified 1 (0·8% ) 4 (2·8% ) 0 (0·0% ) 0 (0·0% ) 5 (0·7% )

Cot death 0 3 0 0 6
Others 1 1 0 0 2

Total 127 142 197 192 658

HMD: hyaline membrane disease; IVH: intraventricular haemorrhage; NS: not significant.

Table IV. Site of anomaly in the early neonatal deaths

Years 1979- 1983 1984- 1988 1989- 1993 1994- 1998 Grand total

Total congenital anomaly 53 73 83 104 313

Neural tube defect 3 12 17 15 47
Chromosome 2 4 4 3 13
Inborn error of metabolism 1 0 7 5 13
Congenital heart disease 7 8 10 12 37
Renal abn. infantile polycystic 0 2 3 7 12
Multiple anomalies 19 17 17 24 77
Hydrocephalus 3 5 5 3 16
Potter’s syndrome 3 7 1 15 26
Down’s syndrome 2 0 1 3 6
Diaphragmatic hernia 3 4 4 4 15
Skeletal abnormalities 5 5 3 1 14
Others 5 9 11 12 37

Total 53 73 83 104 313

Preeclampsia. This was the predisposing factor in the
loss of 17 (2%) babies. The percentage of stillbirths
related to pre-eclamptic toxaemia varied between 1 and
3% over the four 5-year periods.
Antepartum haemorrhage. Abruptio placentae was the
cause of death in 46 (75·4%) babies of the 61 who
died as a result of severe antepartum haemorrhage.
Mechanical. A total of 64 (7·9%) babies died as a
result of mechanical problem. Fifty-five babies died
as a result of cord accidents (nine cord prolapse and
46 true knot/tight cord around the neck or body). In
nine cases, ruptured uterus was to be blamed. The
trend showed a steady decline from 11% of the cause
for the second 5-year period to 5·9% in the fourth
period.
Maternal disease. This was the underlying cause in
the loss of 79 babies. Over half the cases had diabetes
mellitus. The trend over the four 5-year periods
remained static.

Figure 2. Perinatal mortality rate, Riyadh Armed Forces
Hospital (1979–1998). ( u perinatal mortality rate; n stillbirth
rate; s early neonatal death rate).
Unexplained. No cause was identified in over one-third
of the stillbirths (236/807), half of whome weighed
over 2·5 kg. Despite all the improvements in maternity
services, the trend remained the same.
Intrapartum asphyxia. This was the leading cause of
death in 44 babies, which accounts for 5·4% of the
total stillbirths. Caesarean section failed to save eight
babies, 14 were delivered normally and 16 had an
assisted breech delivery. The trend showed a steady
decline from 11·3% in the first period to 2% in the
fourth period.
Placental insufficiency. Some element of growth
restriction and placental insufficiency was evident in
52 (6·4%) stillbirths. Despite the extensive use and
availability of modern methods of fetal monitoring and
availability of good antenatal care, the trend of growth
restriction pick-up as a risk factor remained the same
over the years.
The first 5 years of the study had the highest still-
birth rate of 10·3 per 1000, which then levelled off in
the other periods (Figure 2).
Discussion
The wide institutional variation in classifying perinatal
deaths makes international comparison difficult. All sta-
tistics on perinatal mortality in Saudi Arabia are
hospital-based (Mesleh, 1985; Mesleh, 1986; Swailem
et al., 1988; AI Najashi, 1991; AI Faraidy et al., 1993;
Hashim and Anokute, 1994; Asindi et al., 1998).
An average perinatal mortality of 14.1 per 1000 to-
tal births was similar to that reported from other
tertiary hospitals in Saudi Arabia (Asindi et al., 1998)
and much lower than 40 per 1000 deliveries reported
from Libya (Taushanova, 1998). The perinatal mor-
tality rate of teenage mothers who comprised 17% of
total deliveries was 9·1 times the Swedish rate
(Swailem et al., 1988).
Only 1–2% of newborns have congenital abnormal-
ity, yet it is responsible for a much greater proportion
of mortality and morbidity in infancy, childhood and
during pregnancy (Stock and Jones, 1997). Lethal con-
genital anomalies (0·5% of newborns) accounted for
(508/1465) 34·7% of total perinatal deaths compared
to 24·1% from AI Khobar, Saudi Arabia (AI Najashi,
1991).
Changing trends in perinatal deaths, Saudi Arabia 53
Nearly half of the neonatal deaths and one-quarter
of the stillbirths are due to lethal congenital malfor-
mations. Congenital anomalies discovered early in
pregnanc y, by ultrasound, could have been eliminated
if termination of pregnancy had been carried out. This
is not allowed on a religious basis and mothers have
to continue their pregnancy until viability, when induc-
tion of labour can be carried out. Termination of
pregnancy will only be authorised if continuation of
pregnancy endangers the mother’s life.
A list of lethal congenital anomalies, which are in-
compatible with life once diagnosis is confirmed, can
be drawn and offered termination of pregnancy once
permission is agreed by Religious Affairs. This list and
permission will prevent the abuse of such procedures.
The most significant factors influencing survival of
the extremely low birth weight infants (< 1000 grams)
to 28 days were gestation and birth weights. Survival
increased from 33% at 24 weeks to 100% at 28 weeks’
gestation and from 29% at 500–599 grams to 87% at
900–999 grams birth weight (Finan et al., 1998).
Two-thirds (67·2%) of our premature babies weighed
below 1000 grams. Every effort should be made to pro-
long pregnancy to maturity. Tocolysis and antenatal
corticosteroids must be given to reduce the number of
infants admitted to NICU with prematurity and breath-
ing difficulty. Antenatal assessment of cervical length
and dilatation in high-risk groups will help in identify-
ing cases which are prone to have premature labour,
where cervical cerclage may be of benefit. This, in turn,
may help in reducing the number of handicapped ba-
bies born with extremely low birth weight.
Obstetricians have always been at the forefront of
clinical audit. All maternity units should have regular
monthly perinatal mortality and morbidity meetings to
discuss all perinatal deaths, especially of normally
formed infants, which should be audited and analysed
annually. There is evidence that in some hospitals lit-
tle importance is attached to audit meetings, attendance
is poor, especially at consultant level. The safest
method of delivery should always be adopted. Safe
obstetrics has been the aim in most obstetric units. No
obstetrician is willing to take the blame for a difficult
forceps delivery, because this boy who was delivered
by forceps did not become a university professor at
the age of 20 years! Better understanding of the avail-
able methods of fetal monitoring, and less resort to
difficult deliveries, helped to reduce intrapartum as-
phyxia as a cause of stillbirth from 11·3% of the total
stillbirths in the first 5-year period to 2% in the fourth
period. Early resort to emergency caesarean section
may have prevented some of the 55 perinatal deaths
related to intrapartum asphyxia.
Factors operating before delivery accounted for
43% of the deaths of normally formed infants. The
most common factors were short gestation, low birth
weight, intra-uterine hypoxia and birth injury (Wood
et al., 1984).
Factors after delivery accounted for 33%, the most
common being infection and sudden infant death. In
the remaining 24%, it seemed that a combination of
factors before and after birth had led to death. Fac-
tors before birth thus played a part in two-thirds of
all neonatal deaths (Wood et al., 1984). Factors oper-
ating before delivery can be treated by preventive
measures in the form of treating any maternal infec-
54 R. A. Mesleh et al.

Table V. Causes of stillbirths

Years 1 9 7 9 - 1 9 8 3 198 4- 1 988 1 9 8 9 - 1 9 9 3 1 9 9 4 - 1 9 9 8 Grand total P

1. Congenital anomaly 19 27 64 85 195

14·4 % 17·5 % 27 ·6% 29·4 % 24·1 % < 0 ·01
Neural tube defect 8 9 11 25 53
Others 11 18 53 60 142

2. Hydrops fetalis 1 0· 6 11 15 33
7% 3·9 % 4 ·7% 5·2 % 4·0 % NS
Immune (Rhesus) 0 0 5 3 8
Non-immune 1 6 6 12 25

3. Toxaemia of pregnanc y 4 3 7 3 17
3·0 % 2·0 % 7 3 ·0% 1·0 % 2·0 % NS
Pre-eclampsia 3 3 7 3 16
Eclampsia 1 0 0 0 1

4. Antepartum haemorrhage 14 12 15 20 61
10·6 % 7·8 % 6·4% 6·9 % 7·5 % NS
Abruptio 6 9 15 16 46
Unknown 8 3 0 4 15

5. Mechanical 13 17 17 17 64
9·8 % 11·0 % 7·3% 5·9 % 7·9 % NS
Cord accident 9 14 15 17 55
Ruptured uterus 4 3 2 0 9

6. Maternal disease 11 14 23 31 79
8·3 % 9·0 % 10 ·0% 10·7 % 9·8 % NS
Hypertension 0 2 3 1 6
Renal 0 2 1 4 7
Cardiac 1 0 4 4 9
Maternal infection 1 2 1 2 6
Diabetes mellitus 8 5 11 18 42
Others 1 3 3 2 9

7. Unexplained 42 44 61 91 238
31·8 % 28·5 % 26 ·3% 31·5 % 29·5 % < 0 ·05
< 2·5 kg 16 21 27 59 123
³ 2·5 kg 26 23 34 32 115

8. Asphyxia: intrapartum 15 13 10 6 44
11·3 % 8·4 % 4 ·3% 2·0 % 5·4 % < 0 ·00 1
Caesarean 3 2 3 0 8
Method of Normal 3 5 3 3 14
Delivery Forceps 3 0 0 0 3
Ventouse 1 1 1 3
Breech 5 5 4 2 16

9.· Placental insufficiency 9 15 14 14 52

6·8 % 9·7 % 6·0% 4·8 % 6·4 % NS

10. Unclassified 4 3 10 7 24
3·0 % 2·0 % 4·3% 2·4 % 3·0 %

Total 132 154 232 289 807

NS: not significant.

tion, tetanus immunisation, nutritional supplementation,
correction and treatment of severe anaemia, folic acid
supplementation, screening for gestational diabetes and
combined antenatal diabetic clinics for diabetic patients.
Factors operating after delivery can be dealt with
by basic newborn resuscitation, which should be car-
ried out by a skilled attendant. Risk of infection can
be reduced by principles of cleanliness at birth, includ-
ing a clean delivery surface, clean hands of the birth
attendants, sterile field and sterile gloves, clean instru-
ments to cut the umbilical cord. The risk of
hypothermia can be reduced by thermal protection and
drying and covering of the baby. Early initiation and
establishment of breast-feeding is as important.
The biggest contribution to perinatal mortality sta-
tistics is from stillbirths. In our hospital, stillbirths
accounted for 55% of the total perinatal deaths, and
when congenital anomalies were excluded this contri-
 Changing trends in perinatal deaths, Saudi Arabia 55

Table VI. Site of anomaly in stillbirths

Years 1979- 1983 1984- 1988 1989- 1993 1994- 1998 Grand total

Total congenital anomaly 19 27 64 85 195

Neural tube defect 8 9 11 25 53
Infantile polycystic kidneys 0 0 2 1 3
Potter’s syndrome 0 1 1 2 4
Multiple abnormalities 4 7 26 34 71
Conjoined twins 1 0 0 0 1
Pena Shokeir syndrome 0 1 0 0 1
Zellwegar syndrome 0 2 0 0 2
Hydrocephalus 4 5 11 5 25
Robert’s syndrome 0 0 1 0 1
Thanatophoric dwarf 0 0 1 0 1
A cardiac monster 0 0 1 0 1
Dandy Walker 0 0 1 2 3
Varter syndrome 0 1 0 0 1
Congenital sialodosis 0 1 0 0 1
Others 2 0 2 8 12

Total 19 27 64 85 195

bution increased to 64%. Thirty per cent of stillbirths References

received no antenatal care. Early booking and serial ul-
trasound scanning for growth may have saved some
of these unbooked stillbirths.
Nearly one-third of our stillbirths were unexplained.
The clinical and diagnostic systems currently in use
are unable to identify many fetuses at risk of death. A
decrease in the rate of unexplained antepartum still-
births awaits the discovery of new preventable causes,
or of innovation in clinical or laboratory aspects of
obstetric care (Allesandri et al., 1992).
Many stillborn babies are small for gestational age.
Many antepartum stillbirths, currently designated as
unexplained, may be avoidable if slow fetal growth
could be recognised as a warning sign (Gardosi et al.,
1998).
‘You may take note for twenty years, from work-
ing tonight at the bedside of the sick, upon disease of
the viscera, and all will be to you only a confusion of
symptoms, a strain of incoherent phenomena. Open a
few bodies and this obscurity will disappear’ (Rushton,
1998). Post mortem examinations may help to resolve
and answer some of the causes of death of the ‘un-
explained’ group. This is not allowed in Saudi Arabia
on religious grounds.
Conclusion
Congenital anomalies and low birthweight/prematurity
accounted for 563/658 (85·5%) of neonatal deaths. For
the neonatal death rate to be reduced further, these two
causes have to be dealt with. Congenital anomalies and
unexplained intrauterine fetal deaths which accounted
for 53·6% of total stillbirths. Proper antenatal care and
good ultrasound scan facilities will help greatly in di-
agnosing congenital anomalies and selective termination
of those incompatible with life would reduce the still-
birth rate further.
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