TITLE PAGE

FACTORS CONTRIBUTING TO THE PREVALENCE OF PERINATAL

MORTALITY IN TORIT STATE HOSPITAL

A research dissertation submitted in partial fulfilment of the requirement

for the award of the diploma in clinical medicine and public health of Torit
Health Science Institute (THIS)

BY

NUER ANJELO LORIO AYONYANG

CO/3192/2023

MAY 2023

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 DECLARATION
I Nuer Anjelo Lorio Ayonyang declare that factors contributing to the prevalence of perinatal
mortality in Torit state hospital is my own original work compiled with the guidance of my
supervisor, and that to the best of my knowledge has not been submitted for a diploma or
degree in any other institute, college, university or published elsewhere. Where reference was
made from other sources published or otherwise, that source has been duly cited.

Signature ________________________ Date ________________

NUER ANJELO LORIO AYONYANG

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 CERTIFICATION
I the undersigned hereby certifying that, this dissertation is the original work of Nuer Anjelo
Lorio Ayonyang carried out during his studies under my guidance and direct supervision. I
therefore confirm that I have read and convinced with its authenticity and hereby recommend
the candidate for the examination of the research entitled; Factors contributing to the
prevalence of perinatal mortality in Torit State Hospital. This is to confirm that this
dissertation has not been presented in the institute for the award of any other diploma.

Signature: ________________________________ DATE: _______________

THOMAS AMANYA (Supervisor)

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 ACKNOWLEDGEMENTS

I thank God for giving me wisdom, knowledge and strength to complete this study.

I am grateful to the many people who in different ways contributed to the successful
completion of this research proposal. I deeply acknowledge the able guidance of my
supervisor Thomas Amanya for his insightful suggestions, comments and constructive
criticisms during the writing of this proposal.

I will forever be grateful to my beloved brother James Anjelo and Bishop Joseph Nyerizi who
has been supporting me throughout my academic life. My special thanks to my tutors at Torit
Health Science Institute and the administration of the institute for their invaluable support
and being readily available to help wherever needed. I am also wholly indebted to my family
and friends for their unconditional support and encouragement throughout my academic life.
God bless you all.

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 DEDICATION
To my great and beloved brother James Anjelo;

Thank you for your constant encouragement, support and unfailing love. Not forgetting my
beloved one Aliza Rafael who has been loving, caring and supportive. And above all my
votes of thanks to Almighty God who has always turned my challenges to opportunities of
growth.

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Table of Content
TITLE PAGE............................................................................................................................i

DECLARATION.......................................................................................................................ii

CERTIFICATION....................................................................................................................iii

DEDICATION...........................................................................................................................v

LIST OF TABLES...................................................................................................................xii

LIST OF ACRONYMS..........................................................................................................xiv

DEFINITION OF KEY TERMS.............................................................................................xv

ABSTRACT............................................................................................................................xvi

CHAPTER ONE: INTRODUCTION........................................................................................1

1.0 Introduction........................................................................................................................1

1.1 Background.........................................................................................................................1

1.2 Statement of the problem..................................................................................................3

1.4 Significance of the study....................................................................................................4

1.5 Research questions.............................................................................................................4

1.5.1 Broad question.................................................................................................................4

1.5.2 Specific questions.............................................................................................................4

1.6 Study objectives..................................................................................................................5

1.6.1 Broad objectives..........................................................................................................5

1.6.2 Specific objectives............................................................................................................5

1.7 scopes of the study...............................................................................................................5

1.7.1 Scope of content or subject...............................................................................................5

17.2 Scope of geographical area................................................................................................5

1.7.3 Scope of time.....................................................................................................................5

1.7 Conceptual framework.........................................................................................................6

CHAPTER TWO : LITERATURE REVIEW..........................................................................8

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2.0 Introduction......................................................................................................................8

2.1 Major causes of perinatal mortality...............................................................................8

2.2 Maternal socio-economic factors associated with perinatal mortality..........................9

2.3 Association between antenatal care factors and delivery process...............................10

CHAPTER THREE: METHODOLOGY................................................................................11

3.0 Introduction.....................................................................................................................11

3.1 Research design or study type........................................................................................11

3.1.1 Quantitative approach..................................................................................................11

3.1.2 Descriptive design..........................................................................................................12

3.1.3 Retrospective design......................................................................................................12

3.2 Reseach setting or study area..........................................................................................12

3.3 study population...............................................................................................................12

3.3.1 Inclusion or Eligibility Criteria....................................................................................12

3.3.2 Exclusion Criteria.........................................................................................................13

3.4 Sample size........................................................................................................................13

3.5 Sampling techniques/procedure......................................................................................14

3.6 Research instruments.......................................................................................................14

3.7 Study variables.................................................................................................................14

3.8 DATA COLLECTION.......................................................................................................15

3.9 Data analysis.....................................................................................................................15

3.10 Quality control...............................................................................................................16

3.11 Ethical considerations....................................................................................................16

3.12 Consent............................................................................................................................16

3.12.1 Confidentiality.............................................................................................................16

3.13 Limitations of the study.................................................................................................16

CHAPTER FOUR: RESULTS................................................................................................17

4.0 Introduction......................................................................................................................17

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4.1 Socio-demographic data of the respondents..................................................................17

4.1.1 Marital status of the respondents................................................................................17

4.1.2 Educational level attained by the respondents...........................................................18

4.1.3 Employment status of the respondents.......................................................................18

4.1.4 Spouse employment status............................................................................................19

4.2.5 Religious status of the respondents..............................................................................19

4.2. Major causes of perinatal mortality in Torit State Hospital.......................................20

4.2.1 Pregnancy outcome for the mothers who delivered in TSH......................................20

4.2.2 Contributors of early perinatal death among deliveries at TSH......................................20

4.3 Maternal sociodemographic factors associated with perinatal death.........................22

4.3.1 Educational level associated with perinatal mortality...............................................22

4.3.2 Socio-economic status associated with perinatal mortality.......................................22

4.4 Association between antenatal care factors and delivery process...............................23

4.4.1 Obstetric care factors associated with perinatal mortality.......................................23

4.4.2 Previous history of stillbirth associated with perinatal death...................................23

4.4.3 ANC visit associated with perinatal mortality............................................................24

4.4.5 Pregnancy outcome associated with perinatal mortality...........................................25

4.4.6 Complication of labor associated with perinatal death.............................................26

4.4.7 Mode of delivery associated with perinatal mortality................................................26

CHAPTER FIVE: DISCUSSION...........................................................................................27

5.0 Introduction......................................................................................................................27

5.1.1 Socio demographics data..............................................................................................27

5.2 Major causes of perinatal mortality...............................................................................27

5.3 Maternal socio-economic factors associated with perinatal mortality........................28

5.4 Association between antenatal care factors and delivery process...............................28

CHAPTER SIX: CONCLUSIONS AND RECOMMENDATIONS.......................................30

6.0 Introduction......................................................................................................................30

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6.1 Conclusion.........................................................................................................................30

6.2 Recommendations.......................................................................................................30

To SMOH................................................................................................................................30

To health professionals and health authorities in Torit State Hospital............................30

To community/pregnant mothers.........................................................................................30

REFERENCES.........................................................................................................................31

APPENDIX I: INTRODUCTORY LETTER..........................................................................34

APPENDIX II: CONSENT INFORMATION AND CONSENT OF THE RESPONDENT..35

APPENDIX III: STUDY TOOL (QUESTIONNAIRE- FACTORS CONTRIBUTING TO

THE PREVALENCE OF THE PERINATAL MORTALITY IN TORIT STATE
HOSPITAL).............................................................................................................................36

APPENDIX IV: STUDY TIME FRAME................................................................................40

APPENDIX V: BUDGET........................................................................................................41

APPENDIX VI: MAP SHOWING TORIT STATE HOSPITAL............................................42

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LIST OF TABLES
Table 1: shows study variables..............................................................................................14
Table 2: Shows the maternal age of the respondents...............................................................17
Table 3:Showing the educational level attained.......................................................................18
Table 4: Showing the employment status................................................................................19
Table 5: Shows the pregnancy outcome for mothers who delivered in TSH...........................20
Table 6: Showing Major causes of perinatal mortality............................................................21
Table 7: Showing educational associated with mortality.........................................................22
Table 8: showing the number of ANC visits of the respondents.............................................24
Table 9: Showing the birth weight...........................................................................................25
Table 10:Showing the complication of labor associated with perinatal deaths.......................26
Table 11:Showing the budget for the study..............................................................................41

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LIST OF FIGURES

Figure 1: Showing a conceptual framework of perinatal mortality...........................................6

Figure 2: Shows marital status of the respondents...................................................................17
Figure 3: A bar graph showing the employment status............................................................18
Figure 4: Shows religious status of the respondents................................................................19
Figure 5:Shows the contributors of early neonatal mortality...................................................21
Figure 6: Showing socio-economic status of the respondents.................................................22
Figure 7: A graph showing the number of parity.....................................................................23
Figure 8: A pie chart showing the previuos history of stillbirths.............................................24
Figure 9: Showing the gestational weeks.................................................................................25
Figure 10:Showing the mode of delivery.................................................................................26
Figure 11: Showing the study time frame................................................................................40
Figure 12 A map showing Torit State Hospital........................................................................42

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LIST OF ACRONYMS

ANC - Antenatal care

EMONC -Emergency Obstetric and Neonatal Care

MCH - Maternal Child Health

MDG - Millennium Development Goal

MOH - Ministry of health

PMR - Perinatal Mortality Rate

SSHDS - South Sudan Household Demographic Survey

SMOH - State Ministry of health

TSH -Torit State Hospital

UNFPA -United Nations Population Fund

UNICEF -United Nations Children’s Education Fund

WHO -World Health Organization

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DEFINITION OF KEY TERMS
Perinatal mortality: perinatal mortality (PM) refers to the death of the fetus after the age of
viability, until the 7th days of life. It equals the sum of stillbirth and early neonatal death.
Perinatal mortality rate: The number of stillbirth plus neonatal death per 1000 total births.
Early neonatal death: This is defined as the death of alive newborn occurring <7 completed
days (168 hours) from the time of birth.
Neonatal period: This is defined as the 1st twenty-eight days of post-natal life. There is
immediate (1st 24 hours), early (1st 7days) and late (8 to 28 days).
Stillbirth: This is defined as death of fetus weighing at least 500g before complete expulsion
or extraction from its mother.
Stillbirth Rate: It is the number of fetal loss prior to or during labor
Pre-Term: An infant born after 24 weeks’ gestation but before 37 completed weeks
Post-Term: An infant born any time after completion of the 42nd week.
Prematurity: refers to any live-born neonate who is delivered before 37 full weeks
according the health professionals in charge at the NICU during admission of neonate and
recorded at the patient chart.
Perinatal Asphyxia: is when a newborn’s Apgar score is below 6 in the fifth minute of life,
or if the child doesn’t cry right after birth, experienced respiratory difficulty, floppiness, loss
of consciousness, the presence of convulsions, and loss of neonatal reflexes.
APGAR SCORE: is a quick way for health professionals to evaluate the health of all
newborns at 1 and 5 minutes after birth and in response to resuscitation

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ABSTRACT
Background: studies show that Africa region has the highest perinatal mortality rate with
more than 5 times than developed countries. In spite of modest improvement of perinatal
mortality rate in South Sudan, the country has recorded one of the worst health outcome
indicators globally. The aim of this study was to determine factors contributing to the
prevalence of perinatal mortality rate among deliveries at Torit State Hospital.

Aims/objective: the aim of this study was to determine the factors contributing to the
prevalence of perinatal mortality rate in Torit state hospital.

Method: This was a cross sectional study conducted in Torit State Hospital, maternity and
maternal child health department. The study population comprised of mothers and their
babies delivered during the study period. A semi-structured questionnaire consisting of
demographic profile of the respondents, the major causes of perinatal mortality, maternal
socio-demographic factors associated with perinatal mortality and association between
antenatal care factors and deliveries. Descriptive analysis was conducted to summarize
characteristics of participants

Results: There were 45 deliveries and 7 perinatal deaths during the study period and 40
mothers consented to participated in the study. Perinatal mortality rate among deliveries at
Torit State Hospital was 175 per 1000 live births. The mean maternal age was 25 years with
the majority being between 14 to 19 years 62%, followed by maternal age of less than 18
years. It is noted that majority of the respondents had no formal education with 58% followed
by the primary level attained by 25% and most of the respondent were unemployed with 33
(83%) while employed with 17%. The results show the major common cause of perinatal
death among deliveries in Torit State Hospital was the preterm birth with 65%, followed by
perinatal asphyxia with 20%. In other hand the researcher found majority of the respondents
has less than 4 ANC visits with 85% which is associated with the perinatal mortality
compared with the respondents who had more than or equal to 4 visits with 15%. Most of the
respondents were of lower socio-economic condition with 80% being of lower class,
followed by the middle class with 15% which associate with perinatal death at TSH. There is
an increased risk of early perinatal mortality in babies delivered with the birth weight of less
than 1500 grams with 83% as compared to weight of greater than 2500grams with 17%,
while the perinatal mortality decline as the baby birth weight increased, and it is statistically
significant. This finding found that spontaneous vertex vaginal delivery dominated with 80%

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over the caesarean section with 20%, which appeared to significantly reduce the perinatal
mortality.

In conclusion: the perinatal mortality rate in Torit State Hospital was more than two fold
higher than the estimated regional perinatal mortality; and level of education, parity, history
of stillbirth, ANC visits, gestational age, weight, number of babies delivered, mode of
delivery and mal-presentation were independent predictors.

Recommendation: the researcher highly recommended that interventions need to focus on

increasing knowledge of danger signs and utilization of skilled maternity care and special
emphasis needs to be given to mothers with a previous history of perinatal mortality and
having obstetric complication. Increased literacy and ANC visits by pregnant mothers which
can reduce perinatal deaths.

Key words: Preterm birth, perinatal mortality,

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CHAPTER ONE: INTRODUCTION
1.0 Introduction
This chapter focused on the Background, Problem Statement, Objectives of Study, study
question, Significance of the study and scope of the study.

1.1 Background
Perinatal mortality is defined as the number of fetal deaths past 22 or 28 completed weeks of
pregnancy plus the number of deaths among live-born children up to 7 completed days of life.
Perinatal mortality rate is presented per 1000 total births (live births and stillbirths) according
to the study in Eastern Ethiopia by (Merga, et al., 2022). Perinatal mortality is a public health
as well as a development problem in low-income and middle-income regions.

These untimely deaths are a mjor public health problem in many developing countries and
have enormous economic, social and health implications for families and society according to
(WHO, 2018) worldwide report. The distinction between a stillbirth and early neonatal death
may be a fine one, which often depends on observing the faint signs of life post-delivery.
Unlike neonatal mortality that accounts for deaths to live birth, perinatal mortality also
accounts for stillbirths, making it a comprehensive indicator for estimating the true level of
mortality around the time of delivery (Chinkhumba Je, 2014). Most of these perinatal deaths
are due to factors occur during pregnancy and childbirth. Perinatal mortality reflects the
health status of health care of the general population, reproductive, antenatal, and obstetric
services for women, health care in the neonatal period. Broader social factors such as
maternal education, nutriton, smoking, alcohol use during pregnancy and socio-economic
disadvantage are also important (Australian Institute of Health and Welfare, 2020).

Acording to WHO global data, 2.4 million children died in the first month of life only in
2019 and approximately 6700 newborn deaths occur every day (WHO , 2021). During the
year 2018, about 2.5 million neonatal deaths and over 2 million stillbirths were reported
among the 6.2 million deaths of children under 15 years globally (UNICEF, 2020). Despite
the decline of global mortality rates in children under 5 years from 93 per 1,000 live births in
1990 to 38 per 1000 live births in 2019, there are currently 2.6 million stillbirths and 2.9
million neonatal deaths each year (Taylor, et al., 2020).

In a study conducted by (Anna, et al., 2022) found that 2.5 million neonates die each year
and 2 million are stillborn worldwide and noted that the vast majority in low and middle

1
income countries where access to necessary care is limited to pregnant women and their
newborn.

Furthermore in study done by (Teshome & Gelebo, 2019) noted that out of about 6 million
perinatal deaths occur globally, 3.3 million were stillbirths and majority (more than 97%)
occurs in low and midlle income countries, in South Asia and sub-Saharan countries. In
developing countries, the survival rate of preterm newborns is very low. Perinatal mortality
rate is five times higher (50 per 1000 total births) in developing countries than that of in
developed countries (10 per 1000 total births).

According to Akombi and Renzaho in 2019, conducted a meta-analyysis of Demographic and

Health surveys on perinatal mortality in Sub-Saharan Africa found the average stillbirth rate
per 1000 total births declined from 24.7 in 2000 to 18.4 in 2015 globally, consequently the
number of perinatal deaths decreased from 5.7 million in 2000 to 4.1 million in 2015, with
95% of these deathsn occurring in South Asia and sub-Saharan African (Blessing, 2019)

Despite the decline of global mortality rates in newborns, there are currently 2.6 million
stillbirths and 2.9 million neonatal deaths each year in Africa and South Asia. However,
Africa has the highest stillbirth rate, and slowest improvement worldwide at 27 (25-32)
deaths per 1000 total live births followed by South Asia at 23(21-26) deaths per 1000 total
live births (Asefa, et al., 2022). Studies revealed that there are significant differences in Early
Perinatal Mortality Rate (PNMR) between d eveloped and developing countries with about
98% of these deaths taking place in developing countries (WHO, 2023). For instance, it has
been noted that PNMR is greater than 5 times higher in Africa tha n in developed countries .

A recent meta-analysis of data from sub-Saharan Africa 2019 reported an overall perinatal
mortality rate of 34.7 per 1000 live births. This is higher than the global estimates of 26.7
deaths per 1000 births and doubles the perinatal mortality rate of 13.6 per 1000 births
reported in Georgia, a country with the highest perinatal mortality in Europe (Manjavidze, et
al., 2019)

A study done by (Arach, et al., 2020) show that perinatal mortality in Uganda remain high at
38 deaths per 1000 births , an estimate greater that the every newborn action plan (ENAP)
target of less than 24 deaths per 1000 births by 2030. This is above the regional estimates for
Eastern Africa (34.5 per 1000 births) and Western Africa (35.7 per 1000 births).

2
It has been found that PNMR in developed countries is around 10 deaths per 1000 births
compared to 50 per 1000 births in developing countries like South Sudan. In normal cases
perinatal mortality are preventable, however in developing countries like South Sudan, most
babies die even without being given a name or recording.

According to Knoema 2020 reported on South Sudan Health neonatal mortality for South
Sudan was 40.2 death per 1000 live births. Neonatal mortality rate of South Sudan fell
gradually live births in 2001 ro 4o.3 deaths per 1000nlive births in 2020 (Knoema, 2020).
South Sudan has high newborn and child death rates in 2019; almost 37,000 children under
age of five died in 2019, nearly half before they had completed their first month of life
(UNICEF, 2017). A reportin 2016 by World bank estimates of 20 countries with highest
neonatal mortaliy and under 5 year mortality rate in world nine were from war-torn countries
was between 139 per 1000 live births in Chad and 93 per 1000 births in South Sudan (WHO,
2016).

Further studies indicate that South Sudan is likely to have one of the highest neonatal
mortality rate globally with about 43 per 1000 live births. Most of these deaths that are over
53 percent occurs in 0 to 28 days of life (MOH, 2023).

Moreover, South Sudan has witnessed one of the slowest progress in reducing under 5-morta
lity rate. In addition to this, the major indicators of maternal mortality ratio have stagnated in
the region with perinatal mortality contributing to three quarter of the deaths in neonatal
period (MOH, 2023). This study aims to determine factors contributing to the prevalenc of
perinatal mortality among mothers in Torit State Hospital.

1.2 Statement of the problem

Acording to WHO global data, 2.4 million children died in the first month of life only in
2019 and approximately 6700 newborn deaths occur every day (WHO , 2021). Despite the
decline of global mortality rates in newborns, there are currently 2.6 million stillbirths and
2.9 million neonatal deaths each year in Africa and South Asia. However, Africa has the
highest stillbirth rate, and slowest improvement worldwide at 27 (25-32) deaths per 1000
total live births followed by South Asia at 23(21-26) deaths per 1000 total live births (Asefa,
et al., 2022).

Perinatal mortality still remains a major public health problem and the leading cause of death
in South Sudan which is in line with a report by Knoema South Sudan Health neonatal
mortality was 40.2 death per 1000 live births. Neonatal mortality rate of South Sudan fell

3
gradually live births in 2001 ro 40.3 deaths per 1000 live births in 2020 (South Sudan >
Health, 2020).

South Sudan has failed to achieve the Millenium Development Goal 4 of reducing child
mortality by two-third within the prescibed duration was indicative of health system
deficiencies and despite concentrated effort to minimise the perinatal mortality rates at the
state level hospital under study through client education, training programmes for doctors and
midwives, decentralising of clinic organization and free management of pregnant women, the
neonatal deaths rates remains a concern at the hospital. An important weakness was
inadequate supporting data on magnitude of the problem and ecological factors of, among
others, early neonatal deaths. Hence, there exists inherent inability to institute objective
measures and strategies that would enhance preventive measurable changes.

In addition to possible lack of awareness by the mothers specifically, and community in

general on the access, availability and utilization of Emergency Obstetric and Neonatal Care
services worsens this grim situation. Henece the need to estbalish the baseline data that will
be reference point on understanding the problem.

Therefore, the researcher in this study is interested in studying factors contributing to the
prevalence of perinatal mortality in state hospital.

1.3 Justification of the study

Regardless of intervention in mitigating the rate of perinatal deaths in South Sudan. The
perinatal mortality remained a great concern. In the year 2022 Approximately 2.5 million
neonates die each year and 2 million are stillborn worldwide and noted that the vast majority
in low and middle income countries where access to necessary care is limited to pregnant
women and their newborn and being the leading 85% of the neonates noted by (Anna, et al.,
2022). The researcher is interested in study the factors contributing to the prevalence of
perinatal mortality in Torit State Hospital.

1.4 Significance of the study

The findings of this study will be relevant to health professionals and government in initiating
evidence based interventions to reduce perinatal deaths. It helped the researcher to gain
knowledge and award of diploma in clinical medicine and public health. It will also be a
reference point for determining factors causing perinatal deaths.

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1.5 Research questions
1.5.1 Broad question
1.What factors are contributing to the prevelance of perinatal mortality at Torit State Hospital

1.5.2 Specific questions

1. What are the major causes of perinatal mortality?

2. How is the maternal socio-economic factors contributing to perinatal mortality?

3. What is the association between antenatal care factors and delivery process with perinatal
mortality?

1.6 Study objectives

1.6.1 Broad objectives
To determine factors associated with perinatal mortality among deliveries at Torit State
Hospital.

1.6.2 Specific objectives

1.To determine the major causes of perinatal mortality rate among deliveries at Torit State
Hospital

2.To find out how maternal socio-economic factors influence perinatal mortality in TSH.

3.To determine association between antenatal care factors and delivery process
with perinatal mortality in TSH.
1.7 scopes of the study
1.7.1 Scope of content or subject
The study was done to determine the factors contributing to the prevalence perinatal of
mortality rate in Torit State Hospital.
17.2 Scope of geographical area
Torit State Hospital is a state civil hospital and referral hospital in Torit county Eastern
Equatoria state. It is a teaching hospital that serves approximately 200,000 population
living around in Torit. The hospital borders the Torit Health Science Institute in the
west, Torit freedom field playing ground in the in the east.
1.7.3 Scope of time
This study was done for five months from January to May 2023 in Torit State Hospital.

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1.7 Conceptual framework

Independent variables
Maternal socio-
demographics factors:
maternal age, gestational age,
education, occupation, parity,
religion Dependent variable
Prenatal events: ANC visits,
ANC complication

Perinatal
Mortality

Independent variables
Labor events:
Prolonged labor, mal-
presentation

Pregnancy outcome:
APGAR score, birth weight

Figure 1: Showing a conceptual framework of perinatal mortality

The conceptual framework upon which this study is based emanates from several interlinked
observations. Socio-economic factors and antenatal care factors adversely affect important
maternal aspects that influence reproduction performance. These include education level,
parity, and gestation at delivery, occupation, religion, age, marital status, ANC attendance,

6
and 1st ANC visit, number of ANC visits, pregnancy complications, mode of delivery, and
intrapartum complications.

Reduction of maternal and neonatal deaths have been comprised in governments, NGOs, and
institutions on the basis of effective interventions on perinatal mortality (PNM). This
underscores the great need of solid based data on the magnitude of perinatal mortality on
governments, communities and families.

When the early perinatal mortality rate (EPNMR) is known, it seems possible to strategize on
programs that target educating the population, interventions that are measurable, and having
studies that are analytical, and can improve interventions and implementation. This in the
long-term contributes on policies development and adoption, and decreasing the perinatal
mortality rate in the country.

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CHAPTER TWO : LITERATURE REVIEW
2.0 Introduction
A literature review discussed the purpose of the literature review which is to develop a strong
knowledge base for the conduct of research and evidence-based practice. The information of
this literature review is reviewed by using internet google scholars, research article and many
journal books. The literature review in this study obtained information on the: major factors
causing perinatal deaths, maternal socio-economic status associated with perinatal mortality
and association between antenatal care factors and delivery process with early perinatal
mortality.

2.1 Major causes of perinatal mortality

In a hospital-based retropective survey conducted by (Mangu, et al., 2020) on trends, patterns
and cause-specific neonatal mortality in Tanzania which may be attributed to newborn,
mother and health system factors. A total of 235689 deaths were recorded and neonatal
deaths accounted for 11% 26630 of the deaths. The majority of neonatal deaths 88% occurred
in the first weeks. So the leading causes of early neonatal death were birth asphyxia 22.3%
and respiratory distress 20.8%, while those of late neonatal death were sepsis 29.1% and
respiratory distres 20%. According to (WHO, 2017) report facts sheet globally found that
one-third 35.7% of neonatal deaths are caused by preterm birth complications followed by
intrapartum complications 29.3%, sepsis 19% and other 16% are severe infections. The first
two factors account for most early neonatal deaths while the latter causes nearly half of late
neonatal deaths.

In study carried out by (Fottel, et al., 2015) on cause-specific neonatal mortality had
annalysis of 3772 neonatal deaths in Nepal, Babgladesh, Malawi and India, close to 80% of
all neonatal deaths are due to three leading causes were prematurity and low birth weight,
perinatal complications and asphyxia and sepsis and infections with variations according to
region and neonatal period. Prematurity seems to be the most significant contirbutor to
neonatal mortality but there are other causes of mortality within this age group.

8
Study conducted by (Kalim, et al., 2019) on a situation analysis of newborn health in
Tanzania found that the three main causes of neonatal death are well known: 32% die from
infections; 27% die from complications of preterm birth; 26% die from birth asphyxia. Up to
two-thirds, or 34,000 newborn lives could be saved if the essential care reached mothers and
babies.

A review on perinatal mortality study conducted by (Nwokoro, et al., 2020) in Nigeria found
that; asphyxia 475 (34%), neonatal infection 279 (20%) and prematurity 242 (17.3%)
accounted for majority of the 1,398 perinatal deaths. Unbooked status, antepartum
haemorrhage, previous perinatal death and maternal age greater than 35 yesars were
associated with increased risk of perinatal deaths

In study carried out by (Ahmed, et al., 2022) in hospital based retrospective cohort study in
Somali region of Ethiopia found that a total of eligible 765 neonates with complete data were
reviewed and included in the study, among 765 between 0 and 7 days received, 99 died early
and 666 survived. Higher proportion 41/99 with 41.4% of small babies below 2000gram died
relative to 184/666 with 27.6% survived. Therefore, the causes of early neonatal mortality at
NICU of Sheik Hassen referral hospital were perinatal Asphyxia was the major caused of
early neonatal mortality, followed by prematurity with 32.3%and 31 with 31.3% deaths,
respectively. Sepsis and congenital anomalies were the third and fourth of early neonatal
mortality respectively, 24 with 24.2% and 8 with 8.1%.

In conclusion, the major causes of perinatal mortality are the complication of preterm birth,
birth asphyxia, prematurity, congential anomalies and low APGAR score. However, the
neweborn lives could be saved if the essential care reached mothers and babies.

2.2 Maternal socio-economic factors associated with perinatal mortality

A study conducted by (Islam, et al., 2020) in Bangledash and 20 other countries on socio-
economic factors associated with neonatal mortality found that about 24.7% of women gave
birth to their children as teenagers. The respondents included in the study for the analysis
were mostly from rural areas (about 68.1% and about 21.9% of women belonged to the
poorest family, while another 19% belonged to a poor family. About 41.5% of mothers ended
up with up to primary level education, 47.1% completed their secondary level education, and
the rest 11.4% managed to complete their education at ahigher level. And about 38.4% of
mothers were deprived of having the facility of mass media, while the rest 61.6% had facility.
About 53.5% of women’s partner completed up to primary level education, while only 15.3%

9
of women’s partner managed to complete their higher level. 41.1% of women had one child
and about 1.3% of women gave birth to a twin child, while the rest gave birth to a single
child. About 51.6% of women gave birth to a male child and among the mother, only 21.9%
are working. Place of delivery was home for about 60.6% of women, and the rest 39.4% gave
birth to their children at the hospital. 74.5% of women took antenatal care visits during their
pregnancy while 25.5% did not. About 67.3% of women gave birth to average sized child,
while the rest 13% and 19% of women gave birth to larger than average and smaller than
average children.

According to the study done in Afghanistan by (Alkibria, et al., 2018) a meta-analysis of

population-based cohort studies found that home deliveries with 55%, illiterate mothers with
82.9%, poor socioeconomic status, families that do not want or plan their last child and lack
of continuum care from maternal to child have been associated with perinatal mortality in a
number of studies.

Furthermore, in Congo a study conducted by (Patel, et al., 2022) on socioeconomic status

index as a predictor of stillbirths, perinatal mortality, a total of 94435 women were consented
for study participation and enrolled in the study and were administered the socioeconomic
status questions resulting to 38,373 (44%) women had low socioeconomic status, 28,448
(32%) moderate socioeconomic status.

In conclusion, this review found that education and socioeconomic status is associated with
perinatal mortality and the disparity remains a significant barrier to utilization of maternal
and child health services. Hence, cost-effective health care interventions such as quality
antenatal care and institutional delivery are needed and should target women of low socio-
economic status. There is much to be done in improving literacy programs at all level of care.

2.3 Association between antenatal care factors and delivery process.

According to the Ethiopia Demographic and Health Survery in 2016 reported on association
between antenatal care follow-up and institutional delivery found that in Ethiopia, 62% of
women had ANC visits during pregnancy but 26% of women gave birth in the health facility.
In this study, there was significant association between antenatal care follow-up and health
facility delivery. The odds of institutional delivery service utilization higher among mothers
who had ANC follow up one to three times and four or more times compared with mothers
who had no ANC follow up during pregnancy (Central Stratistical Agency, 2016).

10
Study on population based nested case control study in Ethiopia found that primi-parous
mother with 56% had high perinatal death mulltipara, mothers who had previous history of
perinatal death during the last pregnancy than their counter parts and also preterm newborn.
The strongest determinant of perinatal death were antepartum hemorrhage and maternal
apnea (Yirgu, et al., 2016).

Study conducted in Kassala, Eastern Sudan found that there was high perinatal among by
using logistic regression among mothers who delivered at home was 63% and had a parity of
more than three children 37% were predictors for perinatal deaths. The study also established
that mothers who utilized antenatal care, slept under mosquito nets and took iron supplement
for at least three months were more likely to experience lower perinatal mortality. Experts
recommended utilization of quality emergency and neonatal care services in a health setting
experiencing crisis in order to reduce perinatal mortality rate. (Abdel, et al., 2014)

Although a study carried out in the USA reported that cesarean deliveries with 53% are more
prone to be associated with higher perinatal mortality than those of vaginal deliveries with
26% many of the cases were complicated cases with higher chances of obstetric
complications that was having a total of 79% of associated factors while that remaining 21%
was for the other risk factors. In addition to, complicated cases being referred for C-section,
quality of C-section services, skill of the providers and timeliness of C-section are also
known risk factors for stillbirths and neonatal mortality in developing countries (Dandona, et
al., 2017).

Inconclusion, experts recommended utilization of quality emergeny and neonatal care

services in a health setting experiencing crisis in order to reduce perinatal mortality.

11
CHAPTER THREE: METHODOLOGY
3.0 Introduction
This chapter described the research design and methodology used in the study. The study
type or research design, study area (research setting), population, sample size, sampling
techniques, study variables, data collection, quality control (Pre-test), study limitations,
vadility and reliability as well as ethical consideration are also discussed.

3.1 Research design or study type

The researcher used a quantitative, non-experimental, descriptive exploratory and
retrospective (ex-post facto) design in order to explore and describe the factors contributing
to the prevalence of the perinatal mortality.

3.1.1 Quantitative approach

In the quantitative research, the data was collected by the use of predetermined, structured
and standardised methods, such as structured questionnaires, structured observations,
structured interviews and measurings tools. The researcher will adopt quantitative approach.
This approach will be revalent for the study because concepts will gives opreational
meanings, prepared audit schedule will be used to collect data. The findings in this study will

12
present in a numerical and statistical form. The researcher makes use of a structured audit
schedule which will predetermine and plan in advance for data collection; thus it could not be
changed once data is collected and the objectivity of data is maintain.

3.1.2 Descriptive design

The researcher in this study chose to use the descriptive design to identify and assess the
factors which contribute to the prenatal deaths at Torit state hospital in Eastern Equatoria,
since more information is needed to explain the factors leading to perinatal mortality in the
hospital under the study. The information will assist in making plans for improving health
care practices if they are lacking, in prevention of prenatal deaths.

3.1.3 Retrospective design

The researcher in this case studied events that had already occurred that led to perinatal
deaths, by using questionnaires. These events could not be manipulated or controlled to affect
the phenomenon under study.

3.2 Reseach setting or study area

This study was carried out at Torit State Hospital (TSH), maternity unit and maternal child
health clinic. TSH is located in Torit county in Eastern Equatoria State (EES), TSH is the
teaching and referral hospital in the state, bordering Torit Health Sciences Institute in the
West and football playing ground Freedom Square in the East , providing a total of about 100
bed capacity. The hospital has department of medicine, surgery, pediatric, obstetrics and
gnecology, nutrition. The Obstetric and Gynecology Department of this hospital consist of
the maternal and child health (MCH)/family planning clinic gynecology ward and maternal
unit. The maternal unit comprises of labor ward, operating theatre, antenatal ward,
gynecological ward, postnatal ward, newborn intensive care unit (NICU), and high risk. It has
capacity of about 30 beds and managed by 1 consultant obstetrician/gynecologist, 4 clinical
officers, 8 midwives and 1 clinical officer in-charge. The maternity unit conduct about 15-25
deliveries per month. Mother and child health department conducts antenatal clinic and the
average monthly antenatal clinic attendance is about 20 patients. Torit State Hospital provide
service to the residence of Torit state capital and other patients referred from the county
hospital. The choice of this setting made it suitable site particularly because of the number of
patients and no similar study done in the setting.

13
3.3 study population
For this study, all lived births and newborn babies delivered in TSH during the study period
comprised of the study population.

3.3.1 Inclusion or Eligibility Criteria

In this study, the researcher used all records of neonatal deaths of babies that were delivered
alive in the hospital under the study with a gestational aged of 28weeks and above, weighing
1000g and above and who died within one week of delivery. A control group included
neonates who were delivered alive in the hospital under the study and those admitted in the
neonatal care unit with a gestational age of 28 weeks and above, weighing 1000g and above.
Babies born to mothers either attending or not attending the antenatal clinic were also
included in the study.

3.3.2 Exclusion Criteria

Perinatal deaths occurring at home or on the way to the hospital or clinic were not included in
this study. Babies, who died weighing below 1000g, even if born alive were not included in
this study. Babies dying after one week of delivery were excluded from the study.

3.4 Sample size

The researcher used the sample size determination formula to calculate the sample size using
the slovency formula:

N
n=
1+ N ( e ) 2

where:

n= sample size

N= size of the target population

e=level of significant(e=0.05)

45
n=
1+ 45( 0.05) ²

n = 40 participants

14
3.5 Sampling techniques/procedure
Consecutive sampling techniques was appropriate for the selection of mothers who delivered
their babies. Study targets 50 women who were met the inclusion criteria recruited after being
informed about the study. Participants were assured of privacy and confidentiality

3.6 Research instruments

Questionnaires were used to collect information from participants consisting of both closed
and open-ended questions. It also contained both numeric and category questions responding
to the objectives as set out to obtained.

3.7 Study variables

Table 1: shows study variables

Determine the overall contributory factors to perinatal mortality

Independent Variables Dependent Variables
1. Total number of deliveries
2. Total number of live births
3. Number of perinatal deaths within the Perinatal deaths
7days of life
4. Perinatal complications at birth

Socio-economic factors

15
 1. Educational level
2. Parity
3. Gestation at delivery
4. Occupation Perinatal deaths
5. Religion
6. Age
7. Marital status

Antenatal /Intrapartum Factors

1. ANC attendance
2. Timing of first ANC visit
3. Total number of ANC visits Perinatal Deaths
4. Pregnancy complications
5. Mode of delivery
6. Post-partum complications

3.8 DATA COLLECTION

A well-structured questionnaire comprising of both close ended and open ended questions
were used to collect data from mothers at maternity and maternal child health where services
are rendered. The questionnaires were designed in English language, but the questions were
asked and explained in both English and the national language that is Arabic. This ensured
better understanding for mothers who have challenges with speaking the English language.
The researcher did the data collection. The overall aim of the study was explained vividly to
the data collectors during the interveiwing time. Data collection was done by distributing the
questionnaires to mothers who were able to read and understand the questions to write to fill
the questionnaire on their own whiles the data collector was still around to explain any
ambiguities. For mothers who were unable to read and write, the questionnaire was filled by
the data collector while they ask the respondents the questions on the questionnaire.

3.9 Data analysis

Data was processed by manual calculation to analyze the data. Graphs, pie and tables was
used for easy analysis in this study.

16
3.10 Quality control
Data was cleaned and checked for entry errors then corrected. Data was backed up in external
hard disk in case there was losss or damage to the original data. Only the principal
investigator and statistician had access to the data.

3.11 Ethical considerations

This was a non-invasive study that involve interviewing mother of babies delivered and were
managed in the labor ward, postnatal, gnecological, and neonatal care unit and at high risk
ward. The names of the patients were not indicated on the questionnaires to maintain
confidentiality. Proposal was submitted to the Ethic and Research committee of Torit Health
Science Institute for approval and the hospital management.

3.12 Consent
Mothers were informed that Nuer Anjelo undergraduate student from Torit Health Science
Institute, department of Clinical Medicine and Public Health and Environment was carried
out a study on factors contributing to the prevalence of perinatal mortality. The mothers were
informed of the purpose of the study, and were not victimized or denied treatment if they did
not wish to participate in the study. The information given remained confidential, and no
name was included on the questionnaire. A written consent was sought before the interview.

3.12.1 Confidentiality

The identity of mothers of the babies were kept anonymous. The information of the mothers
and their babies was only available to the statistician and the researcher for analysis only.

3.13 Limitations of the study

Most patients were discharged 24 hours after delivery. The mothers had to be interviewed
within the 24 hours after delivery.

The researcher encountered limited financial resources and time was not enough to conduct
the study. The language use becoming a barrier in collecting the right information since the
respondents may not understand the language used.Some of the mothers were not willing to
be interviewesd immediately after the loss of babies. In such cases, counselling was done
before commencing interview.

17
CHAPTER FOUR: RESULTS
4.0 Introduction
This chapter presented all the relevant finding from the data collected and represented it
in form of flow chart, table, graphic, pie chart and cluster columns. Nevertheless, the
data collected and interpreted were all from primary source.

4.1 Socio-demographic data of the respondents

Table 2: Shows the maternal age of the respondents

Maternal age in years Frequency Percentage

14-19 years 25 62%

20-34 years 12 30%

Greater than 35 years 3 8%

18
Total 40 100%
Primary source 2023
The age of the respondents is shown in Table 2. The mean maternal age was 25 years with
the majority being between 14 to 19 years with 62%, followed by 30% maternal age between
20-34 years and 8% were mothers of more than 35 years above
4.1.1 Marital status of the respondents
The figure below shows that the majority of the respondents were married with 33 (83%)
mean while the singles were 7 (17%).

A PIE CHART SHOWING MARITAL STATUS OF THE

RESPONDENTS

(7(17%)

Single

Married
33( 83%)

Figure 2: Shows marital status of the respondents

4.1.2 Educational level attained by the respondents

Educational level attained Frequency Percentage

No formal education 23 58%

Primary 10 25%

Secondary 5 12%

College or university 2 5%

Total 40 100%
Table 3:Showing the educational level attained

19
Primary data 2023
In table 3 above the majority of the respondents had no formal education with 23 (58%)
followed by the primary level attained by 10 (25%)
4.1.3 Employment status of the respondents
The figure 3 below shows that most of the respondent were unemployed with 33 (83%) while
employed with 7 (17%)
Fi
A BAR GRAPH SHOWING EMPLOYMENT STATUS OF
THE RESPONDENTS

3300%

32.5

27.5

22.5
700%%
17.5

12.5 17%
employed
7.5
83%
2.5 unemployed

frequency percentage
unemployed 3300% 83%
employed 700% 17%

Primary source 2023

Figure 3: A bar graph showing the employment status
4.1.4 Spouse employment status
Table 4: Showing the employment status

Spouse employment status Frequency Percentage

Unemployed 28 70%

Self-employed 9 23%
7%
Employed 3
100%
Total 40
Primary source 2023

20
In table 4, the spouse employment status of the respondents was higher in unemployed
spouse with 28 (70%) followed by self-employed spouse with 9 (23%).
4.2.5 Religious status of the respondents
The figure 4 below shows that an overwhelming majority of the participants were Christians
with 38 (95%) and the rest were Muslim with 2 (5%)

PIE CHART SHOWING RELIGIOUS STATUS OF THE

RESPONDENTS

2, 5%

christians
Muslim

38, 95%

Primary source 2023

Figure 4: Shows religious status of the respondents

4.2. Major causes of perinatal mortality in Torit State Hospital

4.2.1 Pregnancy outcome for the mothers who delivered in TSH

Pregnancy outcome Frequency Percentage

Alive 33 78%

Dead 7 22%

Total 40 100%
Table 5: Shows the pregnancy outcome for mothers who delivered in TSH
Primary source 2023
Table 5 shows that out of the 40 mothers that give birth during the study period, 33 (78%)
mothers had alive birth with the remaining 7 (22%) mothers having perinatal death. The
perinatal mortality rate among the deliveries at Torit State Hospital during the study period
was 175 deaths per 1000 total births.

21
4.2.2 Contributors of early perinatal death among deliveries at TSH
Figure below shows that stillbirths were experienced by 5 mothers, and out of the 5, 4 (10%)
were Fresh Stillbirth (FSB) and 1 (3%) Macerated Stillbirths (MSB). The remaining deaths
were attributed to Early Neonatal Deaths (END) with 2 (5%). The stillbirth rate was 125 per
1000 total births.

A bar graph showing contributors of early perinatal death.

4.25 4 Frequency Percentage

3.75
3.25
2.75
2.25 2
1.75
No of deaths

1.25 1
0.75
0.25 10% 3% 5%
Fresh Stillbirth Macerated Early Neonatal
Stillbirths Deaths

Frequency 4 1 2 NaN
Percentage 10% 3% 5% #FMT

Primary source 2023

Figure 5:Shows the contributors of early neonatal mortality

Table 6: Showing Major causes of perinatal mortality

Causes of perinatal deaths Frequency Percentage

Preterm birth 26 65%

Perinatal Asphyxia 8 20%

Infections 4 10%

Others ( congenital anomalies) 2 5%

Total 40 100%
Primary source 2023

22
Table 6 shows that the major common cause of perinatal death among deliveries at Torit
State Hospital was the preterm birth with 26 (65%) followed by perinatal asphyxia with 8
(20%). The preterm birth had highest percentage due to most of the mother who participated
had less than 36 weeks of gestations and other causes with 5%

4.3 Maternal sociodemographic factors associated with perinatal death

4.3.1 Educational level associated with perinatal mortality
Table 7: Showing educational associated with mortality

Education level attained Frequency Percentage

No formal education 23 58%

Primary 10 25%

Secondary 5 12%

College or university 2 5%

Total 40 100%
Primary source 2023
In table 7 above presented that perinatal mortalities are associated with lack of education with
23 (58%) followed by the primary education with 10 (25%).
4.3.2 Socio-economic status associated with perinatal mortality
Figure 6: Showing socio-economic status of the respondents
As shown in the figure 6 below, the majority of the respondents had low socio-economic
status with 80% followed by the middle class with only 15% and high being the least with
5%, this is due to lack of jobs and poverty

23
 A pie chart showing socio-economic status
High class
5%
Middle class
15%

Lower class
80%

Primary source 2023

4.4 Association between antenatal care factors and delivery process

4.4.1 Obstetric care factors associated with perinatal mortality
Figure 6 below shows that the majority of the respondents were having less than 3

parities with 30 (75%), while the parity of greater than 4 appeared significantly reduce

perinatal mortality with 10 (25%).

more than 4

less than 3

2.5 7.5 12.5 17.5 22.5 27.5

less than 3 more than 4
Frequency 30 10 NaN NaN
Percentage 0.75 0.25 NaN NaN

Figure 7: A graph showing the number of parity

4.4.2 Previous history of stillbirth associated with perinatal death
As shown in figure 7 below, the obstetric care factor associated with increased perinatal

24
mortality was previous history of stillbirth with 31 (77%) compared with those who had

no previous history of stillbirth with 9 (23%).

A PIE SHOWING THE PREVIOUS HISTORY OF

STILLBIRTH

No
23%

yes
78%

yes No

Figure 8: A pie chart showing the previuos history of stillbirths

4.4.3 ANC visit associated with perinatal mortality

Table 8: showing the number of ANC visits of the respondents

Number of ANC visits Frequency Percentage

Less than 4 visits 34 85%

More than or equal to 4 visits 6 15%

Total 40 100%

The table 9 above shows that the majority of the respondents has less than 4 ANC visits

with 34 (85%) which is associated with the perinatal mortality compared with the

respondents who had more than or equal to 4 visits with 6 (15%).

4.4.4 Gestational weeks associated with perinatal mortality

The figure below shows that perinatal mortality was highly associated with the

gestational age of 28-36 weeks with 36 (90%) with the rate declining significantly more

25
than 36 and 42 weeks of gestations, this trend was statistically significant with 5 (10%).

A BAR GRAPH SHOWING GESTAIONAL WEEK ASSOCIATED WITH

37.5 36
PERINATAL MORTALITY
32.5

27.5

22.5

17.5
Number of the respondents

12.5
6
7.5
90% 10%
2.5

28-36 weeks More than 36 Weeks

Frequency 36 6
Percentage 90% 10%

Gestational weeks

Primary source 2023

Figure 9: Showing the gestational weeks

4.4.5 Pregnancy outcome associated with perinatal mortality
Table 9: Showing the birth weight

Respondents variables Frequency Percentage%

Weight in grams
Less than 1500g 33 83%

Greater than 2500g 7 17%

Total 40 100%

Primary source 2023

26
As shown in Table 10 above, there is an increased risk of early perinatal mortality in babies
delivered with the birth weight of less than 1500 grams with 33 (83%) as compared to weight
of greater than 2500grams with 7 (17%), the perinatal mortality decline as the baby birth
weight increased, and it is statistically significant.
4.4.6 Complication of labor associated with perinatal death
Table 10:Showing the complication of labor associated with perinatal deaths

Respondents Frequency Percentage

Prolonged labor 5 12%

Obstructed labor 7 18%

Mal-presentation 28 70%

Total 40 100%

In women with complication of labor as shown in the table 11 above, early perinatal death
was statistically significant higher for mal-presentation with 70%, followed by obstructed
labor with 18% while 12% being the least.
4.4.7 Mode of delivery associated with perinatal mortality
The figure below explained the mode of delivery which was dominated by the mothers who
had caesarean section with 80% while the spontaneous vertex delivery was 20%. This shows
that the caesarean section had number of mothers experiencing due to the obstetric care and
skilled maternity care that may incur.

27
 A pie chart showing mode of delivery

Spontaneous vertex
vaginal delivery
20%

Caeserean
80%

Figure 10:Showing the mode of delivery

CHAPTER FIVE: DISCUSSION

5.0 Introduction
This study was aimed at determining the factors contributing to the prevalence of perinatal
mortality rate in Torit State Hospital. This chapter discussed the result of the major findings
in relation to the objectives and key variables of the research.

5.1 Discussion of the major findings

5.1.1 Socio demographics data

The researcher found that the mean maternal age was 25 years with the majority being
between 14 to 19 years with 62%, followed by 30% maternal age between 20-34 years and
8% were mothers of more than 35 years above and most of the respondents were married
with 33 (83%) while the singles were 7 (17%). The results also show that the majority of the
respondents had no formal education with 23 (58%) followed by the primary level attained by
10 (25%). The respondents who were unemployed has the highest value of 33 (83%) while
employed with 7 (17) and in the other hand, the spouse employment status of the respondents
was higher in unemployed spouse with 28 (70%) followed by self-employed spouse with 9
(23%). overwhelming majority of the participants were Christians with 38 (95%) and the rest
were Muslim with 2 (5%).

28
5.2 Major causes of perinatal mortality.
In this present study the researcher found that the most common cause of perinatal death
among deliveries in Torit State Hospital was the preterm birth with 26 (65%) followed by
perinatal asphyxia with 8 (20%). The study is consistent with a report by World Health
Organization in 2017 facts sheet globally, one-third 35.7% of neonatal deaths are caused by
preterm birth complications followed by intrapartum complications 29.3%, sepsis 19% and
other 16% are severe infections. The first two factors account for most perinatal deaths while
the latter causes nearly half of late neonatal (WHO, 2017).

This study results were incomparable with a study done in Tanzania on a hospital-based
retrospective survey conducted by (Mangu, et al., 2020) on trends, patterns and cause-specific
neonatal mortality found a total of 235689 deaths were recorded and neonatal death
accounted for 11.3%. The majority of neonatal deaths was 87.5% occurred in the first week,
so the leading causes of early neonatal death were birth asphyxia 22.3% and respiratory
distress 20.8%, while those of late neonatal death were sepsis 29.1% and respiratory distress
20%.

The researcher found that the study is inconsistent with a review on perinatal mortality study
conducted in Nigeria found that; asphyxia 475 (34%), neonatal infection 279 (20%) and
prematurity 242 (17.3%) accounted for majority of the 1,398 perinatal deaths. Unbooked
status, antepartum hemorrhage previous perinatal death and maternal age greater than 35
years were associated with increased risk of perinatal deaths (Nwokoro, et al., 2020).

In conclusion, the researcher noted the identified causes of perinatal deaths in most of the
cases studied. Preterm birth was identified as the commonest cause of both early neonatal
deaths. The perinatal deaths causes should be investigated by pregnancy registration and
follow up help in giving us a better understanding of the causes of perinatal mortality.

5.3 Maternal socio-economic factors associated with perinatal mortality.

The study found that perinatal mortalities are associated with lack of education with 23 (58%)
followed by the primary education with 10 (25%). In addition to, the finding showed that
most of the respondents were of lower socio-economic condition with 32 (80%) followed by
the middle class with 6 (15%) which associate with perinatal death TSH.

Similar finding were noted in a study done in Afghanistan by (Alkibria, et al., 2018) a meta-
analysis of population-based cohort studies found that home deliveries with 55%, illiterate
mothers with 82.9% and poor socioeconomic have been associated with perinatal mortality.

29
The finding is incomparable with a study conducted Congo in 2022 on socioeconomic status
index as a predictor of stillbirths, perinatal mortality, a total of 94435 women were consented
for study participation and enrolled in the study and were administered the socioeconomic
status questions resulting to 38,373 (44%) women had low socioeconomic status, 28,448
(32%) moderate socioeconomic status (Patel, et al., 2022).

In conclusion, this study found that education and socioeconomic status is associated with
perinatal mortality and the disparity remains a significant barrier to utilization of maternal
and child health services. Hence, cost-effective health care interventions such as quality
antenatal care and institutional delivery are needed and should target women of no education
attained and low socio-economic status as well as all women seeking health care services.
There is much to be done in improving literacy programs at all level of care.

5.4 Association between antenatal care factors and delivery process

This study found that perinatal mortality was associated with previous history of stillbirth
with 31 (77%) compared with those who had no previous history of stillbirth with 9 (23%),
majority of the respondents has less than 4 ANC visits with 34 (85%) which is associated
with the perinatal mortality compared with the respondents who had more than or equal to 4
visits with 6 (15%) and perinatal mortality was highly associated with the gestational age of
28-36 weeks with 36 (90%) with the rate declining significantly more than 36 and 42 weeks
of gestations, this trend was statistically significant with 5 (10%).

This results were supported with previous study by (Abdel, et al., 2014) in Eastern Sudan
which showed that antenatal care was a significant protective factors for perinatal death. This
result is similar to a study done in Adisababa, Ethiopia by (Getiye., et al., 2017) in which the
risk of perinatal death was 10.6 times higher when there was previous history of perinatal
loss. This might be explained by previous history of early neonatal death increases the risk of
obstetric complications that affect the perinatal outcome.

The results of this study is consistent with a study conducted in Uganda by (Mubiri, et al.,
2020) shared similar finding found that low birth weight independently conferred a greater
than 10-fold increase in the risk of perinatal death. The association of birth weight with
perinatal mortality is mainly because of prematurity.

In conclusion, antenatal care is one of the key strategies recommended to reduce the risk of
perinatal mortality in any community irrespective of socio-demographic background, ANC
visits to a health facility provide the basis for other ANC services.

30
CHAPTER SIX: CONCLUSIONS AND RECOMMENDATIONS
6.0 Introduction
This chapter entailed the conclusions and recommendation on the findings

6.1 Conclusion
Giving birth is of a great prestige unlike developing countries like South Sudan, is just a
chance to survive the first days of life. About 97 percent of reported global perinatal deaths
take place in low and middle income countries. The high perinatal mortality is accounted by
the fact that the most mothers had one or more high risk factors. Factors identified as
associated with early perinatal mortality were: mother’s with no formal education, parity of
more than 4, mothers with previous history of stillbirth, mothers who had less than 4 ANC
visits, gestational age between 28 to 36 weeks, low birth weight, delivery by caesarean
section, and mothers with mal-presentation. Risk factors can be prevented with preconception
care, effective antenatal care, early investigation and increased visits in later part of
pregnancy along with proper intranasal and neonatal care can reduce perinatal mortality.
These findings are timely given the high perinatal mortality rate in Torit State Hospital.

6.2 Recommendations
Following the research findings, the researcher recommended that:

To SMOH
Improving literacy and number of ANC visits is important to identify high risk factors before
pregnancy and during gestation for appropriate care.

31
The government should work on increasing the staff at all levels to avoid unexpected deaths
of both the mother and newborn or preventable deaths.

Attempts should be made to advance the quality of health care services by advancing health
care of newborns with health conditions.

To health professionals and health authorities in Torit State Hospital

Increase awareness about risk factor of perinatal deaths that can be avoided by regular
antenatal check-up.

Continuous medical education and improving health worker’s resuscitation skills through
facility based training, provision of appropriate essential newborn care to preterm babies at
birth and subsequently and availability of adequate resources.

To community/pregnant mothers
Improved literacy and emphasizing the ANC regular visits

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7. Australian Institute of Health and Welfare, (2020). Stillbirths and neonatal deaths in
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analysis of demographic and Health Surveys. Global Health, 1(2019 july), p. 106.

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Factors associated with perinatal mortality, Adisababa: s.n.

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Sub-Saharan Africa: A meta-analysis of population-based cohort studies.. s.l.:BMC
Public Health.

11. Dandona, et al, (2017). Identification of factors associated with stillbirth in the Indian
state of Bihar using verbal autospy: A population-based study.. PLoS Med. Public
Library of Science, Volume 14, pp. 43-44.

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Fetal Neonatal Ed..

13. Getiye., Fantahun. & Tesfaye.H, (2017). Factors associated with perinatal mortality
among public health deliveries in Adisababa, Ethiopia, annunmatched case control
study. BMC Pregnancy and Childbirth, Volume 17, pp. 245-249.

14. Islam, A. & Biswas, (2020). Socio-economic factors associated with increased
neonatal mortality: A mixed method study of Bangladesh and 20 other developing
countries based on demographic

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16. Knoema, (2020). Neonatal mortality rate; South Sudan >Health, s.l.: s.n.

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Tanzania. International Health, 13(4, July 2021), pp. 334-3343.

18. Manjavidze, et.al, (2019). Incidence and causes of perinatal mortality in Georgia. J.
Epidemiol Glob Health., 9(8), p. 168.

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Demographic Surveillance System, Eastern Ethiopia:. PMCID: PMC9119174|
PMID:3558468, 12(18 may), pp. 74-79.

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20. MOH, (2023). The Republic of South Sudan. The Sudan Household Health Survey
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 32. UNICEF, (2020); Ending preventable newborn deaths and stillbirths by 2030

APPENDIX I: INTRODUCTORY LETTER

35
APPENDIX II: CONSENT INFORMATION AND CONSENT OF THE
RESPONDENT

36
Introduction
My name is Nuer Anjelo Lorio Ayonyang, I am a student pursuing a diploma in the
department of clinical medicine and public health in Torit Health Science Institute. I am
conducting a study entitled: “Factors contributing to the Prevalence of Perinatal
Mortality rate in Torit State Hospital.” The following are the purpose of this study: To
determine the overall causes of perinatal mortality among newborn babies delivered in
TSH during the study period, to associate maternal socio-demographic factors with perinatal
mortality among mothers who delivered within the study period and to associate obstetric
care factors with perinatal mortality among mothers who gave birth within the study period.

Your participation will be purely voluntary. All information obtained in the study will be
treated with utmost confidentiality. I shall NOT use your name in any of my reports.
Participation or non-participation does not come with any financial costs. Equally, no
compensation will be provided for participation in the study. Any examination process that
will be conducted by the researcher will cause no damage to participant. You may ask
more questions about the study at any time or at this moment. You will be informed of
any significant finding

Having read this consent form all my questions have been answered, my signature below
indicates my willingness to participate fully in this study and my authorization to use and
share with others.

I ________________________ after reading and having the study purpose explained to me

by Nuer Anjelo, do hereby give informed consent to participate in the study entitled: “Factors
contributing to the prevalence of perinatal mortality rate in Torit State Hospital.”

APPENDIX III: STUDY TOOL (QUESTIONNAIRE- FACTORS

CONTRIBUTING TO THE PREVALENCE OF THE PERINATAL
MORTALITY IN TORIT STATE HOSPITAL)
Instructions: Put a tick inside the brackets base on your knowledge

A. GENERAL CHARCTERISTICS:

37
Socio-demographic characteristics:

1. What age group do you fall at?

(a) 14-19years [ ]
(b) 20-34years [ ]

(c) more than 35 years

[ ]

2. Marital Status
(a) single [ ] (b) Married [ ]

3. Education level attained (a) Non-formal [ ] (b) primary [ ]

(c) Secondary [ ] (d) college/ university [ ]
4. Occupation:
(a) unemployed [ ] (b) Employed [ ]
Other (specify) ___________________________________

If married, spouse occupation:

(a) Unemployed [ ] (b) employed [ ]

Other (specify) _________________________________________________

5. Religion: (a) Christian [ ] (b) Muslim [ ]

Other (specify)…………………………………………………..

B. SOCIO-ECONOMIC FACTORS ASSOCIATED WITH PERINATAL

MORTALITY

7.What socio-economic status do you fall at?

(a) lower class [ ] (b) Middle class [ ] (c) Higher [ ]

C. ASSOCIATION BETWEEN ANTENATAL CARE FACTORS AND

DELIVERYPROCESS

8.Number of parity (a) less than 3 [ ] (b) greater than 4 [ ]

9.What was the gestational age (a) 28-36 weeks (b) more than 36 weeks [ ]

10. Previous history of stillbirth or early neonatal death

38
(a) Yes [ ] (b) No [ ]

11.Where did you do the delivery?

(a) Delivered at TSH [ ] (b) delivered elsewhere [

Prenatal events:

12.Antenatal care attend

(a) Yes [ ] (b) No [ ]

(c) If yes no of time

(a) <3 visits [ ] (b) >4 visits

13.Gestational age at first attending ANC

(a) 12-16weeks [ ] (b) 20-24weeks [ ] (c) 28-32weeks [ ] (d) 32-36weeks

If attended antenatal clinic, where

(a) Booked at TSH [ ] (b) Booked elsewhere [ ]

14. Did you encounter Antenatal care complication

(a) Anemia [ ] (b) pregnant induced hypertension [ ] (c) Malaria [ ]

(d) PROM [ ]

(e) Other specify________________________________________

(e) Other specify ______________________________________________

15. On set of labor

(a) spontaneous [ ] (b) Induced [ ]

Other specify……………………

39
Pregnancy outcome

16. what was the Pregnancy outcome?

(a) Alive [ ] (b) Death [ ]

17. what was the Birth weight (grams)

Less than 1500grams [ ] (b) greater than 2500grams [ ]

18. Gestational age in weeks

(a)28-36 weeks [ ] (b) 37-42 weeks [ ]

19. what was Apgar score in

1 minute…………… 5 minutes…………

20. what was the Reason for NBU admission?

(a) Birth asphyxia [ ] Meconium aspiration syndrome [ ] Prematurity [ ]

Other specify…………………….

21. what was the Outcome:

(i) Stillbirth (a) FSB [ ] (b) MSB [ ]

(ii) Neonatal death first 24 hours

22. Mode of delivery (a) spontaneous vaginal [ ] (b) Caesarean section [ ]

Labor events
23. Prolong labor (a) Yes [ ] (b) No [ ]

24.Obstructed labor

(a) Yes [ ] (b) No [ ]

25. Mal presentation

(a) yes [ ] (b) No [ ]

Other specify __________________________________________________________

40
 Thank you for your positive participation

APPENDIX IV: STUDY TIME FRAME

Activities Decembe January February March April May

r 2023 2023 2023 2023
2023
2022

Proposal
Development

Ethical
Research
Committee
Approval

Data collection

Data Analysis

Report Writing
and
presentation

Submission of
research
dissertation

Figure 11: Showing the study time frame

41
APPENDIX V: BUDGET

Table 11:Showing the budget for the study

S/NO Items Particulars Quantity Rate Total

1. Stationeries Note book 2 @600 12,00

Pens 4 @150 6,00

Ream 1 4000 4,000

2. Internet Internet 1GB per wk

bundles
8wks @500 4,000
Communication
1500 1,500

3. Printing Dissertation 3 @2500 7,500

Binding books 3 @500 1,500

Questionnaires 6 pages @50 3,00

Emergency 4000 4,000

4. Transport 5500 5,500

5. Feeding Breakfast and

lunch
10000 10,000

6. Hiring
computer
1 15000 15,000

7. Flash disc 1 16GB 10000 10,000

8. Miscellaneous 20000 20,000

9. GRAND TOTAL 85,100 ssp

APPENDIX VI: MAP SHOWING TORIT STATE HOSPITAL

42
Figure 12 A map showing Torit State Hospital

43