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Stillbirths and Antenatal Care at a Rural District Hospital

1989; King Faisal Specialist Hospital and Research Centre; Volume: 9; Issue: 2 Linguagem: Inglês

10.5144/0256-4947.1989.186

0975-4466

Peter Thomassen, Liselotte Langemark, Ravi Kumar,

Global Maternal and Child Health

Original ArticlesStillbirths and Antenatal Care at a Rural District Hospital Peter A. Thomassen, MD, PhD Liselotte Langemark, and Ravi KumarMD Peter A. Thomassen From the Department of Obstetrics and Gynecology, King Khaled General Hospital, Al-Majma’ah, Riyadh Region. Search for more papers by this author , Liselotte Langemark From the Department of Obstetrics and Gynecology, King Khaled General Hospital, Al-Majma’ah, Riyadh Region. Search for more papers by this author , and Ravi Kumar From the Department of Obstetrics and Gynecology, King Khaled General Hospital, Al-Majma’ah, Riyadh Region. Search for more papers by this author Published Online:1 Mar 1989https://doi.org/10.5144/0256-4947.1989.186SectionsPDFCite ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutAbstractA review was made of all the stillbirths during 1986 in a general hospital serving a rural district with approximately 30,000 inhabitants. Of 987 births (fetus weighing more than 500 g), 22 were stillbirths (2.2%). The three most probable causes for this high incidence were lack of adequate antenatal care, grand multiparity (20% of the whole series had their seventh or more delivery), and low birth weight. Circumstantial evidence suggested that undetected diabetes mellitus may be one important factor. It was concluded that a well-organized antenatal care program is of prime importance for lowering of the stillbirth rate.IntroductionDuring the last decade great efforts and large amounts of money have been spent on creating first-class obstetric care in Saudi Arabia. The emphasis has been on inpatient care, but a fundamental part of good obstetric care is a well-functioning antenatal program. A coarse, but valid parameter for the assessment of antenatal care is the stillbirth rate.1,2 A study of the stillbirth rate from a general hospital with a defined catchment area therefore ought to be of general interest.PATIENTS AND METHODSThe Department of Obstetrics and Gynecology at King Khaled General Hospital (KKGH) of Al-Majma’ah has 40 beds and is well equipped with tococardiography and ultrasonography. It became operational during the fall of 1985. The hospital is situated 200 km northwest of Riyadh and serves a population of about 30,000. A large proportion of the people live in hamlets or in the desert, and the median income is low.3 About 30% are non-Saudis.During 1986 no detailed statistics concerning the number of pregnant women who attended antenatal check-ups were recorded, but roughly one third had been seen by a specialist, one third had been examined by a midwife or general practitioner at a dispensary, and the last third had no antenatal check-ups at all (“unbooked”). During the same period, about 80% of the deliveries in our catchment area took place at the KKGH, 10% occurred at the dispensaries, and 10% were home deliveries. These figures were arrived at by examination of the files and by interviews with the doctors and midwives at the dispensaries. A detailed account of every delivery occurring from 1 January through 31 December 1986 was made from the delivery room files and the patient charts.The following definitions have been used.4 Birth was defined as “the complete expulsion or extraction from the mother of a fetus weighing 500 g or more irrespective of weeks of gestation.” Stillbirth was “the complete expulsion or extraction from the mother of a fetus weighing 500 g or more showing no evidence of life.” The stillbirth rate was the number of stillbirths per 1000 births. Perinatal mortality was defined as “stillbirth plus deaths during, or within 7 days after, the delivery of an infant weighing 500 g or more.” The perinatal mortality rate then is the number of stillbirths plus neonatal deaths within the first week per 1000 births.RESULTSDuring 1986 no maternal deaths occurred. Some pertinent obstetric data are shown in Table 1. It is seen that 16% of the parturients were Primipara and an astonishing 20% of the total were grand multiparas (seven or more deliveries). The rate of cesarean section was 7.5%; most were emergency operations. The perinatal mortality was 4.7%. The stillbirth rate was higher among Saudis than non-Saudis (Table 2), but the difference is not statistically significant (chi-square with Yates correction).Table 1. Some obstetric figures from KKGH, 1986.Table 1. Some obstetric figures from KKGH, 1986.Table 2. Stillbirths at KKGH, 1986.Table 2. Stillbirths at KKGH, 1986.Because routine autopsies are not done in the Kingdom, the cause of a stillbirth often remains obscure. Table 3, however, shows the tentative causes.Table 3. Probable causes of stillbirths.Table 3. Probable causes of stillbirths.The number of visible, major malformations was 16 (including three among the stillbirths).DISCUSSIONPerinatal DeathsA perinatal mortality rate of 4.7% is high compared with figures from other developed countries, even when minority groups are studied.5,6 It is difficult to compare our results with previous reports from the Kingdom because most authors define “births” as being infants of more than 28 weeks’ gestational age. A research team headed by Dr. Abdulatif Al-Faraidy, however, in 1986 proposed that the definitions used by WHO should form the basis for the evaluation of perinatal care in the Kingdom.7 This, and the fact that in a majority of our cases reliable data concerning the age of gestation were lacking, made it logical to choose the weight-related WHO definitions.In a study from the Riyadh Military Hospital, Mesleh employed the same definitions as we did.8 He showed a decline in the perinatal mortality rate from 1.44% in 1983 to 1.0% in 1986. The latter rate compares favorably with results from Europe and the United States and is five times lower than ours.Ohlsson, in his extensive discussion of perinatal care in Saudi Arabia, believed a perinatal mortality rate of 3% to 4% to be representative for the country as a whole.9 Compared to that, our figure is not surprising; it merely shows that great improvement can be expected even in rural districts when the antenatal care is better organized and full use is made of already existing hospital facilities.StillbirthsThe stillbirth rate in the present study (2.2%) was roughly half of the perinatal mortality rate (4.7%), a proportion which is commonly found.1,5,6 Three factors seem to be of importance for this very high rate of stillbirths: lack of adequate antenatal care, grand multiparity, and a high percentage of low-birth-weight infants. The marked difference between Saudis and non-Saudis seems to illustrate this. The non-Saudi women who get pregnant are mainly educated Middle Eastern housewives or professionals (mostly teachers). They seem to follow the antenatal program closely, and as a general rule, they are more health-conscious than their Saudi sisters. The rate of grand multiparas among the non-Saudis was 6.3%, while 22% of the Saudi women had their seventh or more delivery. Also, the occurrence of infants weighing less than 2500 g was higher among the Saudis (8.5%) than among the non-Saudis (4.5%).Concerning the causes of the stillbirths, abruptio placentae was found in five cases, and four intrauterine (or early intrapartal) deaths were attributed to cord complications. Better attendance during the last month might have enabled us to identify high-risk symptoms such as bleeding and diminished fetal movements in these patients and thus prevented some of the intrauterine fetal deaths.Preeclampsia, which may be a causative factor in abruptio placentae, is seldom seen in the Kingdom,10 and only one intrauterine fetal death could be ascribed to this condition. Moreover, that patient had grossly neglected the treatment.A further analysis of causes of the stillbirths must be speculative due to the lack of autopsy reports and pertinent laboratory data. In three cases, diabetes in the mother was detected after the stillbirth, but there is reason to suspect that more cases of intrauterine fetal death were caused by untreated diabetes in pregnancy. In 1986 only five cases of diabetes in pregnancy were treated in our department. Screening for diabetes in pregnancy was started in December 1986, and during the first 10 months of 1987, 35 cases of diabetes in pregnancy were treated. Thus, several cases probably went undetected in 1986.The single case of intrauterine fetal death caused by infection occurred in a woman treated at the medical ward for sepsis with hepatosplenomegaly, the cause of which was unknown. The histopathology report showed old and recent infarctions and acute inflammation of the placenta.The most common infection in pregnant women from this area is brucellosis, which is endemic. During the first half of 1987, we treated more than 30 cases. Three of those women aborted during the first trimester, but there were no stillbirths. We cannot draw any conclusions about the possible connection between brucellosis and stillbirths during 1986 from these figures; indeed, the effects of brucellosis on pregnancy in humans are largely unknown.11Sixteen infants, including three intrauterine fetal deaths, were born with visible major malformations. This incidence (1.6%) is consistent with the rather high rates previously reported from the Kingdom,9,10 probably resulting from the practice of cousin marriage. The malformations found in the three stillborns were consistent with intrauterine demise. In the large group of “unknown,” there is reason to suspect that one or more cases were caused by isoimmunization, but no laboratory details are available to support this.Antenatal CareThe all-important factors in the struggle for a lowering of the stillbrith rate seem to be a well-functioning antenatal care program together with avoidance of grand multiparity. We believe that both these factors can be influenced by the obstetrician/midwife, preferably in collaboration with the primary health care officers. From December 1986, we therefore have started a systematic training of the doctors and midwives at the dispensaries in our catchment area. At present 80% of Saudi women and nearly 90% of the non-Saudi women who deliver at our hospital have been to one or more antenatal check-ups and the stillbirth rate during the first 6 months of 1987 was 1.64%.Our preliminary results of intensified antenatal care under continuous supervision of obstetricians and midwives are so encouraging that we want to make it a constant feature of primary health care.ARTICLE REFERENCES:1. Williams RL, Chen PM. "Identifying the sources of the recent decline in perinatal mortality rates in California" . N Engl J Med. 1982; 306(4):207-14. Google Scholar2. Hein HA. "“Secrets from Sweden.”" . JAMA. 1982; 247(7):985-6. Google Scholar3. Serenius F, Fougerouse D. "Health and nutritional status in rural Saudi Arabia" . Saudi Med J. 1981; 2(suppl 1):10-22. Google Scholar4. Chiswick ML. "Commentary on current World Health Organisation definitions used in perinatal statistics" . Arch Dis Child. 1986; 61(7):708-10. Google Scholar5. Buckell EWC, Wood BSB. "Wessex perinatal mortality survey 1982" . Br J Obstet Gynecol. 1985; 92(6):550-8. Google Scholar6. Rahbar F, Momeni J, Fomufod A, Westney L. "Prenatal care and perinatal mortality in a black population" . Obstet Gynecol. 1985; 65(3):327-9. Google Scholar7. Al-Faraidy A. Guidelines for evaluation of perinatal care. Research team: project AR-6-121. Riyadh: Ministry of Health, 1986. Google Scholar8. Mesleh RA. "Stillbirths at the Riyadh Military Hospital (abstract), Symposium on Foeto-Maternal Morbidity and Mortality, Riyadh" ., 8-9March1987. Google Scholar9. Ohlsson A. "Better perinatal care in Saudi Arabia" . Ann Saudi Med. 1985; 5(3):169-78. Google Scholar10. Chattopadhyay SK, Sengupta BS. Chattopadhyay C, et al.. "Maternal mortality in Riyadh, Saudi Arabia" . Br J Obstet Gynecol. 1983; 90(9):809-14. Google Scholar11. Porreco RP, Haverkamp AD. "Brucellosis in pregnancy" . Obstet Gynecol. 1974; 44(4):597-602. Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byEl-Gilany A and Aref Y (2019) Failure to Register for Antenatal Care at Local Primary Health Care Centers, Annals of Saudi Medicine , 20:3-4, (229-232), Online publication date: 1-May-2000.Brunner J and Falana-Olen G (2019) Altered Organization of Antenatal Care in a Rural District, Annals of Saudi Medicine , 9:3, (314-314), Online publication date: 1-May-1989. Volume 9, Issue 2March 1989 Metrics History Accepted11 April 1988Published online1 March 1989 InformationCopyright © 1989, Annals of Saudi MedicinePDF download