CLINICAL CHARACTERISTICS AND FACTORS ASSOCIATEDWITH PERINATAL

DEATH AMONG PREGNANT WOMEN WHO DELIVEREDAT SEKOU TOURE

REGIONAL REFERRAL HOSPITAL,MWANZA-TANZANIA

DEPARTMENT OF OBSTETRICS AND GYNECOLOGY

BY

DR. INNOCENT L.KAIZA; MD,MMED(OBS/GYN)

RESEARCH REPORT SUBMITTED TO THE HOSPITAL MANAGEMENT

© 2023
DECLARATION

I, Dr. Innocent L. Kaiza declare that the work presented is my original work. The contribution of

other people who contributed to the preparation of this work are duly quoted and acknowledged.

This research has not been submitted anywhere for the sake of this purpose.

Signed ……………………………….. Date ………………………….

i
ACKNOWLEDGEMENT

I am very grateful to Almighty God for the gift of life and good health.

I also wish to express my sincere gratitude to the hospital management for their encouragement

and support during the course of this work.

Last but not least, my heartfelt thanks go to all those not mentioned who may have assisted me in

one way or another in accomplishing this research. May the Almighty God bless you

ii
TABLE OF CONTENTS

DECLARATION..............................................................................................................................i

ACKNOWLEDGEMENT...............................................................................................................ii

LIST OF TABLES..........................................................................................................................vi

ABBREVIATIONS.......................................................................................................................vii

OPERATIONAL DEFINITIONS................................................................................................viii

ABSTRACT...................................................................................................................................ix

CHAPTER ONE..............................................................................................................................1

1.0. INTRODUCTION................................................................................................................1

1.1. BACKGROUND..................................................................................................................1

1.2. PROBLEM STATEMENT...................................................................................................3

1.3. RATIONALE OF THE STUDY...........................................................................................4

1.4. RESEARCH QUESTION.....................................................................................................4

1.5. OBJECTIVES.......................................................................................................................5

1.5.1. Broad objective...............................................................................................................5

1.5.2 Specific objectives...........................................................................................................5

CHAPTER TWO.............................................................................................................................6

2.0 LITERATURE REVIEW......................................................................................................6

2.1. Overview:..............................................................................................................................6

2.2. Rates of perinatal deaths.......................................................................................................6

2.3. Factors associated with perinatal deaths...............................................................................7

CHAPTER THREE.........................................................................................................................8

3.0 METHODOLOGY.................................................................................................................8

3.1. STUDY DESIGN AND DURATION..................................................................................8

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 3.2. STUDY AREA.....................................................................................................................8

3.3. STUDY POPULATION.......................................................................................................8

3.4. SELECTION CRITERIA.....................................................................................................8

3.4.1. Inclusion Criteria............................................................................................................8

3.4.2. Exclusion criteria............................................................................................................9

3.5. SAMPLE SIZE ESTIMATION............................................................................................9

3.6. SAMPLING PROCEDURE.................................................................................................9

3.7.0 STUDY VARIABLES..................................................................................................10

3.7.1. Dependent variables:....................................................................................................10

3.7.2. Independent variables:..................................................................................................10

3.8. DATA COLLECTION METHODS...................................................................................10

3.9. FILES COLLECTION........................................................................................................11

3.10. DATA MANAGEMENT AND ANALYSIS...................................................................11

3.10.1. Data management.......................................................................................................11

3.10.2. Data analysis...............................................................................................................11

3.11. ETHICAL CONSIDERATION........................................................................................11

3.12. DISSEMINATION OF RESULTS...................................................................................11

CHAPTER FOUR.........................................................................................................................12

4.0 RESULTS................................................................................................................................12

4.1 Rate of perinatal deaths and social demographic characteristics of women with perinatal

deaths.........................................................................................................................................12

4.2 Clinical characteristics of the study population (women with perinatal deaths).................14

4.3 Causes of early neonatal deaths...........................................................................................17

iv
 4.4 Factors associated with early neonatal deaths in the study population................................18

CHAPTER FIVE...........................................................................................................................20

5.0 DISCUSSION......................................................................................................................20

5.1 Rates of Perinatal death and characteristics (socio-demographic and clinical) of the study

population...................................................................................................................................20

5.2 Causes of early neonatal deaths among neonates admitted in NICU..................................21

5.3 Factors associated with early neonatal deaths......................................................................21

5.4 Limitation of the study.........................................................................................................22

CHAPTER SIX..............................................................................................................................23

6.0 CONCLUSION AND RECOMMENDATION......................................................................23

6.1 CONCLUSION....................................................................................................................23

6.2 RECOMMENDATION.......................................................................................................23

REFFERENCES............................................................................................................................24

APPENDICES...............................................................................................................................27

Appendix 1: Data collection tool...............................................................................................27

v
LIST OF TABLES

Table 1: Socio demographic characteristics of the study population (women with perintal deaths)

(N=169)..........................................................................................................................................13

Table 2: Clinical characteristics of the study population (women with perinatal deaths) (N=169)

.......................................................................................................................................................15

Table 3: Complications in the index pregnancy among the study population (women with

perinatal deaths) (N=169)..............................................................................................................16

Table 4: Causes of early neonatal deaths among neonates admitted in NICU (N=67).................17

Table 5: Apgar score against duration of stay in NICU among early neonatal deaths (N=67).....17

Table 6: Factors associated with early neonatal deaths among the study population.(N=169).....19

vi
ABBREVIATIONS

APH Ante partum Hemorrhage

C/S Caesarean Section

DM Diabetic Mellitus

EHMS Electronic Health Management System

HTN Hypertension

LMICs Low and middle income countries

MMR Maternal Mortality Rates

PNDPerinatal Death

SRRH SekouToure Regional Refferal Hospital

OBGY Obstetrics and Gynecology

PPH Postpartum Hemorrhage

SVD Spontaneous Vaginal Delivery

USA United States of America

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OPERATIONAL DEFINITIONS

Perinatal deaths All neonatal deaths from immediately after delivery up to 7 days of life

among women who came with live intrauterine fetuses.

Low birth weight Birth weight of less than 2kg and equal or more than 1kg(1≥ birth weight

˂ 2)

viii
ABSTRACT

Background:

Perinatal deaths are of importance concern in the field of maternal healthand neonatal care

despite most of efforts being directed in preventing maternal deaths.The current proposed study

is set to rates of perinatal deaths, clinical characteristics of pregnant women and factors

associated with those deaths so as to take specific preventive measures among pregnant women

delivered at SRRH.

Objective:The study aim to determinerate of perinatal deaths, clinical characteristicsand factors

associated with perinatal deathsamong pregnant women who delivered at SRRH, Mwanza-

Tanzania.

Methodology:This was a one (1) year retrospective descriptive study. Patient files(case notes) of

pregnant women who had perinatal deaths between 1 st May 2022 to 30st May 2023and meet the

inclusion criteria were included.

Results: There were 7336 deliveries in the one year of the study, of which 81.1% (n =5953)

were by vagina deliveries and 18.9% (n=1383) by caesarean section. During this period there

were 169 cases of perinatal deaths identified, making a rate of perinatal deaths to be 23 cases per

1000 deliveries (2.3%). All one hundred and sixty nine cases (100%) were available for various

data analysis.Among perinatal death 40%(n=67) were early neonatal deaths and there was an

identified association between referral from lower health facilities with early neonatal deaths.

Conclusion: The rate of perinatal deaths in this study was relatively low as compared to other

studies done in sub Saharan Africa. Majority of the study population had complications in their

ix
index pregnancy and referral from lower heath facilities was more likely to be associated with

early neonatal deaths.

Recommendations: There is a need to put clear strategies protocol and continue to work restless

in order to prevent more incidences of fresh stillbirths among women who come with fetal hearts

presents on admission and early neonatal death

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 CHAPTER ONE

1.0.INTRODUCTION

1.1. BACKGROUND

Perinatal deaths usually poses the challenges to the health care provider, institutions, families

and the communities because it is one of tragedy related to complications of pregnancy and/or

labor and delivery. Perinatal mortality is a major public health concern worldwide with

estimated 2 million stillbirths and 1.8 million early neonatal deaths reported in 2019(1). Perinatal

deaths shows an unexpected new born outcomes and signifies abnormal trends from normal

course of postnatal care(2).{Rodríguez, 2006 #12}First 7 days following delivery of an infant is

the most important period for both the mother and her infant because most of physiological

changes which occurred during pregnancy are resolving towards pre-pregnant state, and also

care of the mother to her infant is believed to be of the highest concern(3). Stillbirth has been

associated with extensive psychosocial consequences for parents and family, and has been linked

to post-traumatic stress disorder, anxiety and depression (4). Stillbirth rates are generally a good

indicator of the quality of care before and during childbirth. The period from the onset of labour

until birth is the most high-risk period for the mother and child, where 45% of all stillbirths occur

(5). Most stillbirths in LMIC are considered to be preventable through provision of quality care

for all mothersand babies (6, 7, 8, 9)

In our setting at SRRH according to Labor and NICU wards registry, unpublished data shows

that there were 213 perinatal deaths between 1 st May 2022 and 30th April 2023. However, there is

no available information on the pregnant women characteristsics and associated factors of

perinatal deaths at SRRH.

1
Thus the aim of this study is to determine the rate of perinatal deaths, patient characteristics and

factors associated with perinatal deaths among women delivered at SRRH, MwanzaTanzani

2
1.2. PROBLEM STATEMENT

Perinatal deaths are among the important challenges facing the field of maternal health

worldwide over the years.There are several factors that are associated and contributes to

increased and persistent perinatal deaths such as pre-eclampsia,ante-partum

hemorrhages,prematurebirth,low birth weight,low apgar score,non cephalic presentations and

poor monitoring of labor progress.

In our settings, rate of perinatal deaths,clinical characteristics and factors associated with

perinatal deaths among pregnant women delivered at SRRH was not yet to be studied. It is

through this knowledge gap, I believe this proposed study will document clearly the clinical

characteristics of studied pregnant women and factors associated with perinatal deathsamong

pregnant women who delivered at SRRH.

3
1.3. RATIONALE OF THE STUDY

Here at SRRH there is noinformation addressing the causes of perinatal deaths andfactors

associated withperinatal deaths among pregnant women who delivered here.

I believe this study will establish the rate of perinatal death,clinical characteristics of studied

women and factors associated withperinatal deaths in our setting.

Also the findings that will be obtained from this study will provide evidence-based basis to

address the specific gaps in the quality of obstetric care, and neonatal care which willhelp the

department of Obstetrics and gynecology and Paediatrics in better understanding of patient’s

process and factors related to preventable perinatal death. This will enable us to improve care to

our patients in general and prevent these perinatal deaths.

1.4. RESEARCH QUESTION

What are the rate of perinatal death, clinical characteristics and factors associated with

perinatal deaths amongpregnant women who delivered at SekouToure RRH, Mwanza-

Tanzania?

4
1.5. OBJECTIVES

1.5.1. Broad objective.

To determine therate of perinatal death, clinical characteristics and factors associated with

perinatal deaths among pregnant women who delivered at SRRH, Mwanza Tanzania.

1.5.2 Specific objectives.

1. To determine the rate of perinatal death amongpregnant women who delivered at SRRH,

Mwanza Tanzania.

2. To determine the clinical characteristics of pregnant women with perinatal

deathsamongwomen who delivered at SRRH,Mwanza Tanzania.

3. To determine the factors associated with perinatal death amongpregnant women who

delivered at SRRH, Mwanza Tanzania.

5
 CHAPTER TWO

2.0 LITERATURE REVIEW

2.1. Overview:

There is significant improvement in the understanding of maternal health care services and

newborn care all over the world in both developed and developing countries, also comprehensive

obstetrics care are emphasized in order to have good outcome to the newborn

infants(10,11,12)The available literature suggests that several risk factors for stillbirth are

common across LMICs (13). These risk factors may vary among countries depending upon the

availability of resources for provision of care, as well as access to care by remotely located

populations. The lack of a functional vital registration system also appears to be associated with

high stillbirth rates (14, 15). Perinatal deaths are silent problem and still is given little attention in

most countries as compared to maternal deaths, in which most of factors which cause perinatal

deaths are the ones which are also implicated directly to cause maternal complications and deaths

(16).

2.2. Rates of perinatal deaths

One of the study from sub-saharan Africa reported perinatal deaths of 34.7 per 1000

births(17).This is higher than world estimates of 26.7 deaths per 1000 births(18) and doubles the

rates of 13.6 deaths per 1000 birth reported in Georgia which is considered to be highest in

Europe(19).

6
Another study done in Uganda in 2007 showed that there is perinatal death rates of 70 deaths per

total 1000 births which is unacceptable high (20).A study done in Pemba Tanzania in 2019 by

Tine Skytte and collegues showed that the rate of 22 per 1000 total births (21).

2.3. Factors associated with perinatal deaths.

In a study done by Chacha D and collegues in 35 hospitals in Tanzania between 2006 and 2015

showed that 22.3% and 20.8% of perinatal deaths were caused by birth asphyxia and respiratory

distress respectively(22).

A study done by FransiscaChuwa in Tanzania in 2017 showed that pre-eclampsia and abruptio

placenta were the strongest maternal factors associated with stillbirths.And also non-cephalic

presentation and low birth weight were the fetal factors with the greatest impact on still birth(23).

Another study has shown that women who underwent emergency (unscheduled) C/S had high

chance of having fetal complications as compared to those whom C/S were done under elective

(scheduled) basis(24,25,26).

Another studies have shown that maternal co morbidities( like HTN, DM, chronic anemia,

psychosis),those who received treatment for prematurity and postpartum blood transfusion have

increased chance of having fetal complications and subsequent fetal deaths(27,28,29)

Women who deliver after use of oxytocin for induction of labor have been associated with

increased risk of comorbidity and even fetal complications(30)

A study done in England in 2015 showed that there is increased risk of delivery complications in

which most of them leads to perinatal deaths in women who deliver in weekends as compared to

their counterparts who deliver in weekdays (31)

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 CHAPTER THREE

3.0 METHODOLOGY

3.1. STUDY DESIGN AND DURATION

This was a 1 year retrospective descriptive hospital based study of allpregnant women who had

perinatal deaths from 1st May 2022 to 30thMay 2023. Study was conducted for 5-months (April-

August 2023) period for all case notes which meet the inclusion criteria.

3.2. STUDYAREA.

The study was conducted at SRRH. This is a regional referral hospital for Mwanza Regional. It

serves all eight districts of Mwanzareginal and also receives patients from nearby regions of

Simiyu,Shinyanga and Geita (32).

On average, there are about 20-25 deliveries per day at SRRH some of which are referrals from

lower heath facilities within the aforementioned areas.

3.3. STUDY POPULATION

The study included all case files ofpregnant women who delivered at SRRHand had perinatal

deathsbetween 1st May 2022 and 30th May 2023.

8
3.4. SELECTION CRITERIA

3.4.1. Inclusion Criteria

1. Pregnant women who delivered at SRRH between 1 st May 2022 and 30th May 2023 and

had (perinatal deaths) freshstill birth and/or her new born died within 7 days after being

admitted in Neonatal wards.

2. Pregnant women who delivered babies weighing 1000g and above or gestational age of

more than 28 weeks.

3.4.2. Exclusion criteria

1. Patients’ files with inadequate information.

3.5. SAMPLE SIZE ESTIMATION

According to hospital registry extractions between 1st May 2021 and 30th May 2022, the total

numbers of perinatal deaths were 80 fresh stillbirths and 133 early neonatal deaths which make a

total of 213 perinatal deaths.

Using Yamane, Taro formula,1967 and assumption that power to demonstrate statistical

significance to be 95%, the minimum sample size will be calculated using(33)

n= ___N___
1+N (e) 2

Where,

n=minimum sample size.

N = 213( Number of perinatal deathsbetween 1st May 2022 and 30th May 2023).

e = Tolerable error which was set to be 5%. (0.05)

n= 132

9
A minimum sample size will be estimated to be 132.

3.6. SAMPLING PROCEDURE

Purposive sampling technique was used; the sample size was obtained from pregnant women

who delivered at SRRH and got perinatal deaths from 1st May 2022 to 30th May, 2023.

Patients’ files (case notes) with adequate information among those women with perinatal deaths

were included as per inclusion criteria.

3.7.0 STUDY VARIABLES

3.7.1. Dependent variables:

Perinatal deaths: early neonatal death and fresh stillbirth.

3.7.2. Independent variables:

Demographic characteristics,gestational age, referralstatus, type of labour,mode of delivery, birth

weight and Apgar score.

3.8.DATA COLLECTION METHODS

The required data were sourced from all patient files (case notes) for women who delivered at

SRRH from 1st May 2022 to 30th May 2023 and meet the inclusion criteria.

Hospital numbers of patients’ files for those pregnant women who had fresh still births and those

neonates admitted at Neonatal ward will be searched up in Labor ward and Neonatal ward

register at SRRH. These (patients’ file numbers) were important to trace up patients’ files (case

notes) in the Afya care.

10
A structured, pretested data collection tool was used just to determine the missing information

from the respective patient files (case notes) by the investigator. The same data collection tool

was used in all patients files(case notes).

Information that was collected included: Socio-demographic and clinical characteristics, factors

associated with perinatal deaths.

3.9. FILES COLLECTION

The investigator was responsible for collection of patients’ files from SRRH HMS-Afya care and

Health Records Department.

3.10. DATA MANAGEMENT AND ANALYSIS

3.10.1. Data management

Data collected were verified at the end of each day by an investigator and entered in a computer

using unique study number for each patient. All the data were stored in a database which was

protected by password ready for analysis.

3.10.2. Data analysis

All data collected from this study were entered to the computer Microsoft excel 2007 and then be

transferred into STATA version 13 for analysis. Categorical variables will be summarized into

proportions and percentage while numerical variables in mean, median and standard deviation.

All independent variables were exposed to univariate logistic regression model and those with p

value of 0.2 or less were exposed to multivariate ordinal logistic regression model. Independent

variable with pvalue of less than 0.05 were considered significant.

11
3.11. ETHICAL CONSIDERATION

The study approval was sought from the hospital research committee of SRRH. Name

and other identity of the client were hidden to keep confidentiality. The benefits that were

obtained from the study for using secondary data outweigh their risks.

3.12. DISSEMINATION OF RESULTS

The results of the study will be submitted to the hospital management of SRRH and effort will be

made to publish the study findings in a peer reviewed journal.

CHAPTER FOUR

4.0 RESULTS

4.1 Rate of perinatal deaths and social demographic characteristics of women with

perinatal deaths.

During the one –year period of study from 1 st May,2022 to 30th May,2023,there was a total of

7336 deliveries at SRRH, of which 81.1% (n=5953) were by vaginal deliveries and 18.9%

(n=1383) were by caesarean sections.

There were 169 perinatal deaths identified during the study period, of which 60% (n=102) were

fresh stillbirths and 40% (n=67) were early neonatal deaths.All of these perinatal deaths were

available for various data analysis.

The rate of perinatal deaths in this study was found to be 23 perinatal deaths per 1000 deliveries

(2.3%).

12
Majority of the study population were aged below 35years 81.7% (n=138) and above 35 years

were only 18.3% (n=31) (Table 1).Most of the study population reside in urban 73.4% (n=124),

and were multipara (˃1) 66.3% (n=112) (Table 1).

Also most of the study population had primary education 84.0% (n=142), and they were

housewife 81.7% (n=138) (Table 1).

Table 1: Socio demographic characteristics of the study population (women with perintal
deaths) (N=169)

Variable Frequency(n) Percentage (%)

Age(years)
<35 138 81.7
≥35 31 18.3

Parity
Primepara (1) 57 33.7
Multipara (˃1) 112 66.3

Residence
Urban 124 73.4
Rural 45 26.6

Education
Primary 142 84.0
Secondary/College 27 16.0

13
 Occupation
Housewife 138 81.7
Employed/Business 25 14.8
Peasant 06 3.5

4.2 Clinical characteristics of the study population (women with perinatal deaths).

As mentioned ealier most of women 60% (n=102) had fresh stillbirth and 40% (n=67) had early

neonatal deaths.Among those with fresh stillbirths 42.6% (n=43) came with fetal heart present on

admission and 57.4% (n=59) fetal heart were absent on admission. (Table 2)Among women with

early neonatal deaths 58.2% (n=39) had low Apgar score after delivery and 41.8% (n=28) had

normal apgar score. Furthermore 33.3% (n=22) died within 24 hours and 66.7% (n=45) died

after 24 hours (Table 2).

Of all cases that were evaluated in the study population, 62.7% (n=106) were admitted at SRRH

as self-referral from home while 37.3% (n=63) were admitted as referral cases from lower health

facilities, moreover majority of these women had their delivery at gestation age of 37weeks or

more and 56.8% (n=96) had gestational age below 37 weeks (Table 2).

14
Greater number of the study population had spontaneous onset of labor 84.6% (n=143) and most

of them delivered by spontaneous vagina delivery 73.4% (n=124) (Table 2).Also significant

number of women in the study population delivered in normal weekdays 70.4% (n=119) and

others 29.6% (n=50) delivered during weekends,yet many women their deliveries were

conducted by nurses (midwives) 74.0% (n=125).In the study population most of women had

blood loss after delivery of less than 500mls 65.1% (n=110). More over most of women 61.0%

(n=103) delivered normal birth weight babies and 39.0% (n=66) delivered low birth weight

babies (Table 2). Supplisingly in this study 31.4% (n=53) of women had no any complication

during pregnancy while 68.6% (n=116) had complications in their index pregnancy (Table 3).

Obstetric hemorrhages was the leading complication 39.7% (n=46), followed by

pre-eclampsia/eclampsia 34.5% (n=40) and premature rupture of membranes 6.0 %( n=07)

(Table 3)

Other complications and their frequency and percentages are shown in table 3.

Table 2: Clinical characteristics of the study population (women with perinatal deaths)
(N=169)

Variable Frequency(n) Percentage (%)

Patients’ admission
From home 106 62.7
From lower health facility 34 37.3
Gestation age during delivery(weeks)
<37 73 43.2
≥37 96 56.8
Type of labor
Spontaneous 143 84.6
Induced 23 13.6
Elective caesarean section 03 1.8
Mode of delivery
Spontaneous vagina 124 73.4
Emergency caesarean section 42 24.2
Elective caesarean section 3 2.4

Blood loss after delivery (mls)

15
<500 110 65.1
≥500 59 34.9
When delivery was conducted
Normal weekdays 119 70.4
Weekends 50 29.6
Which time of a day was delivery conducted
Day time 94 55.6
Night time 75 44.4
Who performed the delivery
Nurse midwife 125 74.0
Medical officer 43 25.4
Medical specialist 01 0.6
Birth weight
Normal 103 61.0
Low birth weight 66 39.0
Type of perinatal deaths
Early neonatal death 67 39.6
Fresh stillbirth 102 60.4
Apgar score among early neonatal death
Normal 28 41.8
Low score 39 58.2
Duration of stay in NICUbefore death
Within 24 hours 22 33.3
More than 24 hours 45 66.7

Table 3: Complications in the index pregnancy among the study population (women with
perinatal deaths) (N=169)

Variable Frequency(n Percentage (%)

Complications in the index pregnancy

Yes 116 68.6

No 53 31.4

Common complications in the index pregnancy(N=116)

Obstetric hemorrhages 46 39.7

Pre-eclampsia/eclampsia 40 34.5

16
 Premature rupture of membranes(PROM/PPROM) 07 6.0

Prolonged labour 06 5.2

Cord prolapse 05 4.3

Preterm labour 04 3.4

Ruptured uterus 02 1.7

Severe anemia 02 1.7

Others 04 3.4

4.3 Causes of early neonatal deaths

In our study, we found that the leading cause of early neonatal deaths was intrapartum asphyxia

45.4% (n=31).The second cause was respiratory distress syndrome 19.7% (n=13) followed by

neonatal sepsis 15.2% (n=10) and prematurity 12.1% (n=08) (Table 4).Other causes of early

neonatal deaths are shown in (table 4) below.

Also in this study it was found that among those newborn with low apgar score,significant

number of them died after 24 hours 60.0%(n=24),as compared to 40%(n=15) who died within 24

hours (Table 5).

Table 4: Causes of early neonatal deaths among neonates admitted in NICU (N=67)

Causes of early neonatal deaths Frequency(n) Percentage (%)

Intrapartum asphyxia 31 45.4

17
 Respiratory distress syndrome 13 19.7
Neonatal sepsis 10 15.2
Prematurity 8 12.1
Meconium aspiration 4 6.1
Low birth weight 1 1.5

Table 5: Apgar score against duration of stay in NICU among early neonatal deaths (N=67)

Duration of stay in NICU

Apgar score Within 24 hours More than 24 hours Total

Normal 06(18.5%) 22(81.5%) 27(45.0%)

Low score 15(40.0%) 24(60.0%) 40(55.0%)

Total 21(31.3%) 46(68.7%) 67(100%)

4.4 Factors associated with early neonatal deaths in the study population.

In this study factors associated with early neonatal deaths were assessed against other type of

perinatal deaths.

On univariate logistic regression analysis (table 6) women who were 35 years old or above

(OR1.4; 95%CI[1.0-1.9]; p value =0.062) were more likely to have early neonatal deaths

compared to those whom their age were below 35 years.Women who were multipara (OR

1.8;95%CI[0.9-3.5];p value 0.074) were associated with early neonatal deaths compared to

primipara.Moreover those women who were reffered from lower health facilities (OR

2.4;95%CI[1.2-4.7];p value 0.010) and those with blood loss of more than 500mls(≥500mls)(OR

2.8;95%CI[1.3-6.1];p value 0.011) were strongly likely to have early neonatal deaths compared

to their counterparts.

18
Furthermore women who did not have any complications in their index pregnancy (OR

0.5;95%CI[0.3-1.0];p value 0.044) were less likely to have early neonatal deaths.

When these five (05) associated factors were exposed to multivariate logistic regression analysis

(table 6), only one factor was significant. That was those women whom were admitted as referral

cases from lower health facilities (OR 2.0; 95%CI [1.0-4.3]; p value=0.049) had more chances of

having early neonatal deaths compared to those women who were admitted as self referral from

home. Table 6 summarizes factors associated with early neonatal deaths.

19
 Table 6: Factors associated with early neonatal deaths among the study population.(N=169)

Variable
Category Early Univarient Multivarient
neonatal
deaths
Yes No OR[95%CI] P- OR[95%CI] P-
n(%) n(%) Value Value
Age(years) ˂35 58(42) 80(58) 1.0
≥35 09(29) 22(71) 1.4(1.0-1.9) 0.062
Parity Primepara(1) 28(49) 29(51) 1.0
Multipara(˃1 39(35) 73(65) 1.8(0.9-3.5) 0.074
)
Residence Urban 53(42.7) 71(57.3) 1.0
Rural 14(31.1) 31(68.9) 1.6(0.8-3.5) 0.174
Patient From home 50(47.2) 56(52.8) 1.0
Admission From lower 17(27.0) 46(73.0) 2.4(1.2-4.7) 0.010 2.0(1.0-4.3) 0.049
facilities
Complication in Yes 40(34.5) 76(65.5) 1.0
index No 27(50.9) 26(49.1) 0.5(0.3-1.0) 0.044
pregnancy
Mode of SVD 45(36.3) 79(63.7) 1.0
delivery Emergency 20(47.6) 22(52.4) 0.7(0.3-1.3) 0.254
C/S 03(100) 00(00) 0.2(0.02-1.9) 0.156
Elective C/S

Blood loss after ˂500 49(44.5) 61(55.5) 1.0

delivery(mls) ≥500 18(30.5) 41(69.5) 2.8(1.3-6.1) 0.011

20
 CHAPTER FIVE

5.0 DISCUSSION

To the best of researches done here at SRRH, I believe this was the first study of its kind to be

done in our institution. The aim of our study was to evaluate our own experience in the quality of

obstetric care we are providing to our clients here at SRRH and to determine the rate of perinatal

deaths, clinical characteristics of women with perinatal deaths and factors associated with early

neonatal deaths.

5.1 Rates of Perinatal death and characteristics (socio-demographic and clinical) of the

study population

In this study the rate of perinatal deaths was found to be 23 deaths per 1000 births (2.3%) which

is almost similar to the study done in Pemba Tanzania in 2019 which was 22 deaths per 1000

births (2.2%) (21). This rate of perinatal deaths is lower than that reported in Uganda in 2007

which was 70 deaths per 1000 births and world average estimate of 26.7 deaths per 1000

births(20,18) but seems to be higher than that reported in Georgia 13.6 deaths per 1000 births

which is highest in Europe(19). The observed differences in rates of perinatal deaths could be

due to differences in sample size and also quality of obstetric services between these settings.

Another explanation could be other women decide to send their new born who had early

complications in their nearby health facilities.

Majority of women in this study 68.6% had complication during pregnancy and/or delivery. This

could be because most of women are educated about the danger signs during pregnancy when

they attend routine ANC visits and are instructed during that whenever they had any danger sign

they have to go straight to the tertially hospital.That is why most of them had complications but

they came as self referral from home.

21
5.2 Causes of early neonatal deaths among neonates admitted in NICU

In this study it was found that the leading cause of neonatal deaths was intrapartum asphyxia

45.4% followed by respiratory distress syndrome 19.7%. These findings are similar to the study

done in 35 hospitals in Tanzania by Chacha D and collegues (22). Possible explanations for these

findings could be in our study population there were majority of women who had obstetrics

hemorrhages,pre-eclampsia/eclampsia and premature rupture of membranes as complications in

their index pregnancy that may increase risks of stillbirths the same as what was found in a study

done by FransiscaChuwa in 2017(23).

Also in this study it was found that most of early neonatal deaths among those with low apgar

score occurred after 24 hours 60% compared to 40% which occurred within 24 hours.The

possible explanations for this could be there is significant improvements in knowledge of

neonatal resuscitation among health care workers in labor ward and neonatal care in general in

our NICU ward.

5.3 Factors associated with early neonatal deaths.

In this study factors associated with early neonatal deaths were assessed against other type of

perinatal deaths.

On multivariate logistic regression (table 6), it was observed that in our study women whom

were admitted as referral cases from lower health facilities ( p value=0.049) had chances of

having early neonatal deaths when compared with those women who were admitted as self-

referral from home. The possible explanations for the observed association results could be those

women who were reffered from lower health facilities there were some delays to have early

intervention from the indications of their referral into our hospital.

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5.4 Limitation of the study

Though this study found important findings, there was a limitation as well. That there were

difficulties in searching of information because there is a lot of mismatching between patients

names, surnames and registration numbers.

23
 CHAPTER SIX

6.0 CONCLUSION AND RECOMMENDATION

6.1 CONCLUSION

The rate of perinatal deaths in this study was relatively low as compared to other studies.

Majority of the study population were admitted as self-referral from home. Those pregnant

women who were referred from lower health facilitieswere observed to be associated with early

neonatal deaths.

6.2 RECOMMENDATION

 There is a need of the same study to be done in other facilities within the region so as to

establish the true burden of perinatal deaths.

 Still there is a need to work restless from the level of antenatal clinics to our facility so as

to emphasize on the strategies to reduce perinatal deaths.

24
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APPENDICES

Appendix 1:Data collection tool

Data Collection Form (English version): Write the number of your response in the given space.

Socio-demographic data of study women population

No Question Response

1. Serial number

2. Date of Data review

3. Patient File number(mother):

Patient File namber (neonate):

4. Age (number): 0= <35

1= ≥35
5 Parity (number): 0=Primepara
1=Multipara
6 Residence: 0=Urban
1=Rural
7 Education: 0=Primary

1=Secondary/College

8 Marital status: 0=Married

1=Not Married
9. Occupation: 0=Housewife
1=Employed/Business
2=Peasant
10. Mode of Cost sharing: 0=Out of pocket
1=Health insurance

28
Clinical characteristics (factors associated) information of a women

No Questions Response

11. Patients’ admission: 0= From home

1= From lower health facility
12. Gestational age during delivery(weeks): 0=˂37
1=≥37
13. Complications in the index pregnancy: 0= Yes
1=No
14. Common Complications in the index pregnancy:0=Pre-eclampsia/eclampsia
1=Obstetric Hemorrhages(APH&PPH)
2=Premature rupture of membranes
3=Prolonged labor
4=Ruptured uterus
5=Others
15. Type of labor: 0=Spontaneous
1=Induced
2=Elective caesarean
16. Mode of delivery: 0=Spontaneous vagina.
1=Emergency Caesarean section
2=Elective caesarean section
17 Blood loss after delivery (mls) : 0=˂200
1=200-500
2=˃500
18. When delivery was conducted: 0=Normal weekdays.
1=Weekends.
19. Which time of a day was delivery conducted: 0= Day time
1=Night time
20. Who performed the delivery: 0= Nurse

29
 1=Medical officer
2=Medical specialist
21 Birth weight: 0= Normal
1=Low birth weight
22 Type of perinatal death: 0=Early perinatal death

1=Fresh stillbirth

23 Fetal heart status among fresh stillbirth: 0=Not present

1=Present

24 Apgar score among early neonatal deaths: 0=normal

1=low score

25 Duration of stay in NICU before death: 0=Within 24 hours

1=More than 24 hours

26. Causes of early neonatal death:0=Intrapartum asphyxia

1=Respiratory distress syndrome

2=Meconium aspiration

3=Neonatal sepsis

4=Neonatal jaundice

5=Prematurity

6=Low birth weight

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31